by Chris Hicks & Andrew Petrosoniak
A case of logistics
“Oh shit, my tray just got dumped.”
A 24-year-old male has been stabbed in the chest four times. Hypotensive, tachycardic, hypoxemic. Combative, no vascular access. A bit better now, dissociated with IM ketamine. Hard at work on getting a subclavian cordis in place, the emergency medicine senior resident lays out their gear in the only spot available – on the stretcher, between the patient’s ankles. The patient kicks, and the tray is launched on a brief parabola. It hangs in the air for what seems like an hour before crashing to the floor with a disheartening clang. A passing nurse steps on the wayward introducer needle. It bounces along in the sole of his Birkenstock and spins off, lost forever in the untold vastness of under-cabinet jetsam.
The EM senior ponders the situation for a split-second. “I’m going to need another cordis kit”, she says. “And I need some flushes too. And caps. And do we have more prep sticks?”
From the surgery senior: “Careful, I need to reach around you to get the cardiac POCUS done.”
They bump elbows a few times. “Hey, just let me … Please mind the sterile field.”
From the head of the bed, the anesthesia fellow has been watching this all play out with rising consternation. He gestures with a gloved finger along the hemi-circumference of the resus bay. The walls are lined with rows of metal equipment carts and opaque blue bins, the contents of which are unknown to all but their creator. “Should we activate the MHP?” he says, to nobody in particular.
Crowding and poor design produce very real threats to patient and provider safety, made all the more pressing in the era of COVID-19. Photo: Patrick Schnell MD, New York Magazine
Emergency medicine is hard – and we make it harder
Hey, we’ve all been here. It’s no secret that hospital equipment, spaces and systems are routinely not optimized to facilitate the high stakes, time dependent, tightly coupled work of resuscitation teams. But the roots of the problem run deeper than we might appreciate. Making things work in difficult situations is part of the emergency medicine ethos – culturally we take pride in our ability to overcome systemic barriers to patient care. And while there’s growing recognition that relying on individual rather than system resilience is creating a burnout and patient safety epidemic, our self-flagellating attachment to toughing it out has also created a degree of learned helplessness when it comes to proposing viable solutions. (1)
Learned helplessness: An elephant can be taught not to break free of their chains, even though they could do so in an instant.
It doesn’t have to be that way. Creating the resuscitation environments of the future means that the end user – both patient and provider – are placed at the centre of the design process. And making that happen requires advocacy, empathy, participation, and the right tools to bring it all together.
The current state is broken
Creating new acute care equipment and workspaces is hard, and the complexity therein can be difficult to visualize. Pitfalls in design don’t always jump off the page when looking at a clinical care pathway, protocol or design schematic. Large scale projects like the construction of a new emergency department can be particularly challenging to conceptualize, as early abstractions give way to project delays, endless compromise, and decision fatigue. The compulsion to get anything done often supersedes the more laborious task of getting it done right. The people in charge of projects of this scale are universally skilled, thoughtful, and well-intentioned. But a board room is no place for solving design problems of the complexity imbued by modern resuscitation – that needs to be felt, held, and experienced in situ. The best project managers in the world won’t get it right if they don’t have the right tools to do so.
The future is simulated: Simulation-informed clinical design
To most people, the idea of driving a car that hasn’t been adequately crash tested seems ludicrous. Design and planning notwithstanding, it’s hard to know how safe a vehicle is until its smashed into a wall a few times to observe the outcomes. Complex health systems are no different: It's hard to know where the gaps in safety are if you don't go looking for them in the first place.
Simulation is a powerful tool to interrogate the safety, efficiency and ergonomics in high stakes environments. Traditionally used to train people, procedures and teams, simulation-informed clinical design puts the system itself as the unit of analysis, and places the user — patient AND provider — in a position to offer feedback relevant to system improvement. The resulting deep activation and engagement is then leveraged in a subsequent debriefing session, wherein facilitators talk participants through the scenario, asking curious questions and generating rich data and feedback.
Self, team, environment, system: Simulation is a powerful tool to integrate all components of complex systems, from analysis and development to construction and implementation. Photo: Katie Cooper and Yuri Marakov, Unity Health Toronto.
Gary Klein described the pre-mortem as powerful tool to inform high stakes decision-making: Ideating with “prospective hindsight” what future success and failure might look like. Simulation can operationalize the pre-mortem process by re-creating successes and failures, and allowing end-users to quite literally interact with them. (2)
Simulation-informed design builds in stages: a current state analysis helps form a “view from 20 000 feet” of a given system and its complexities. From there, it is possible to gradually increase precision of design iterations using an array of simulation modalities — scale and full sized mock-ups, virtual reality and augmented reality, and finally testing the new space.
Current state analysis using in situ simulation allowed our research team to observe patterns of movement in our trauma — data that was used to radically re-imagine and re-design how equipment and space was utilized in constructing our new trauma bay. (3)
Simulation-based mock up analysis can be used to prototype and test design interventions (image right) aimed at decreasing personnel bumps, congestion, and sterility violations. (4)
All procedures are not equal: Our in situ simulation work helped to categorize three types of trauma equipment — bedside critical care, high frequency use, and everything else — and then create and prototype clinical logistics solutions for each. Photo: Katie Cooper and Yuri Marakov, Unity Health Toronto
In our experience, findings from a simulation-informed design process can be broken down into two general categories:
The known unknowns: Data is a more powerful driver for change than anecdote. Codifying and quantifying known issues by way of a current state analysis can inform process improvement to a greater extent than incident reports and hallway conversations. Even if everyone already knows there’s an issue —
“It takes way too long to get blood to the bedside in trauma”
— the data from targeted in-situ simulations can substantiate those observations in ways that are hard to ignore:
“Our simulations demonstrated an average delay to blood product delivery of X minutes, which is associated with an increase in patient mortality of Y”
The unknown unknowns: Sometimes, you don’t know something is a problem until it’s a problem. Once you know there’s an issue, simulation can help you get to the root of the problem. Turns out, delays in blood product delivery were due in part to the circuitous path our blood runners had to take to get to the blood bank, and not knowing how or when to announce themselves when they got back.
Data and observation inform better decisions for process improvement. In the case of improving blood product delivery times, revising the massive hemorrhage protocol would have done nothing to make the process better or faster. Instead, a human-focused solution to shorten the distance traveled and facilitate awareness upon arrival decreased blood product delivery times from 11.5 minutes to 9 minutes, an improvement that is associated with a 12.5% decrease in mortality for trauma patients. (5)
When it comes to marginal gains and massive hemorrhage protocols, sometimes the solution is as simple as giving the blood runner a recognizable spot to stand. A consistent “porter stop” leverages positive defaults, making it easier for people to exhibit a preferred behaviour.
The case for less
In a healthcare system hungry for additional capacity, the desire for more can drive decision-making, without considering if more translates to better. At St Michael’s Hospital in Toronto, the design for a new trauma bay included expanding from two to three stretchers, ostensibly to care for 50% more critically injured patients at any given time.
Added capacity has advantages but presents challenges as well, many of which are difficult to see. These latent hazards are threats to patient and provider safety that aren’t easily identified until they create a problem, which carries the potential for adverse events and harm.
We used simulation-informed clinical design to put both our old and new trauma bays through their paces. To do so, we brought a number of simulation modalities to bear, selected based on the task at hand:
- Current state analysis: In situ simulation exercises based on known difficult trauma cases, run with the full team in the “old” trauma room
- Hazard matrix, framework analysis and video review with the help of human factors engineers
- Table-top talk throughs of the new space, using scale models and design schematics
- Full scale simulations in mock-ups of the proposed new space, pre-construction
- In situ simulation in the constructed new space, prior to opening for clinical care
At every step, our findings were shared with the design and project management teams. Turns out, the crowding of three stretchers created a series of negative trade-offs and limited the ability to deliver safe and timely care. What followed was a reworking of the space and design to feature a two stretcher steady state with the ability to flex up to three if necessary, clear floor markings to preserve the circle of care around the patient’s head, neck and torso, and clinical logistics to support bedside critical care procedures. (6)
How it's going: Design concepts for the new trauma space included nudges for PPE, 360 degree access around the head and torso, all-position sightlines to equipment and monitors, modular carts to support bedside procedures, floor markings and a viewing room for crowd and traffic control. Photo: Katie Cooper and Yuri Marakov, Unity Health Toronto
Getting it done, right: Formalizing user-designer-builder partnerships
The MacLeamy Curve speaks to a very simple but important principle in project management: design changes become more costly and less effective the farther along they occur (7), underscoring the importance of getting it right from the beginning.
Providers are not architects, contractors or project managers, nor should they pretend to be. Formalizing partnerships between builders and end-users is absolutely critical. To be effective, simulation-informed design can't happen in a bubble, but rather it should bring all relevant parties to the table to co-create, prototype and test solutions prior to implementation. A nurse with a design idea for a resuscitation room layout needs to be able to interface with an architect to create a rendering, simulationists to crash test and generate feedback, and project managers to cost, plan and implement solutions.
The MacLeamy curve and diminishing returns: The longer you wait to fix bad design, the more expensive and less effective those changes become. (7)
You can’t see what you don’t look for. Simulation-informed clinical design harnesses the collective knowledge and engagement of care providers to mitigate danger and drive innovation, in ways that no planning meeting ever could. In the future, new tools like virtual and augmented reality will further enhance the simulation and design process, as will analysis by way of live event recording and artificial intelligence. (8) We can build better systems, safer spaces, systemic resilience — what's required is an investment in the people, tools and ideas to make it happen. Simulation-informed clinical design is a central plank in that platform precisely because it puts that which matters most — patient and provider — at the centre of a design process. That's the sort of progress we'd all like to see.
Christopher Hicks and Andrew Petrosoniak are emergency physicians, trauma team leaders, simulation specialists and principals at Advanced Performance Healthcare Design in Toronto, Canada.
(1) Wied M, Oehmen J, Weilo T. Conceptualizing resilience in engineering systems: An analysis of the literature. The Journal of the International Council on Systems Engineering, 2020. 23: 3-13
(2) Daniel Kahneman’s Favorite Approach For Making Better Decisions. Farnam Street Blog. Accessed on November 12, 2020. Available at: https://bit.ly/2IvfcFF
(3) Petrosoniak A, Almeida R, Pozzobon L et al. Tracking workflow during high-stakes resuscitation: the application of a novel clinician movement tracing tool during in situ trauma simulation. BMJ Stel, 2019; 5: 78–84
(4) Shultz J, Borkenhagen D, Rose E, et al. Simulation-Based Mock-Up Evaluation of a Universal Operating Room. Health Environments Research and Design Journal, 2019. 13(1): 68-80
(5) Petrosoniak A, Gray S, Pavenski K et al. The clock is ticking: using in situ simulation to improve time to blood delivery in bleeding trauma patients, 2019. 21 Suppl 1: S40-S41
(6) Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review, 2020. BMJ Quality & Safety Published Online First: 23 October 2020
(7) Kaftan M. Cognitive Building Systems. Optimization Algorithms in Architecture from Design to Production. Thesis paper. Accessed on November 12, 2020. Available at: https://bit.ly/2JYnupT.
(8) Nolan B, Hicks C, Petrosoniak A et al. Pushing boundaries of video review in trauma: using
comprehensive data to improve the safety of trauma care. Trauma Surg Acute Care Open, 2020. 5: e000510