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In Situ Progressive Site Interprofessional Simulation as a Tool for Quality Improvement in Transitions of Care

Ryan Thompson, MD
Joshua Ross, MD


Transitions of care, particularly involving handoffs between different care teams such as the transfer of a patient from the Emergency Department to the ICU, are inherently risky times in patient care. However, tools available to study these transitions are limited. Simulation is well known as a tool for education, but it can also be utilized to “test” a complex hospital system.

In situ progressive site simulation is a simulated experience that engages a global work system by following a patient care scenario through multiple clinical environments. This tool can be utilized to meet a broad range of needs, from purely observational (needs assessment), to evaluating the patient experience, experimenting and testing new workflows, or even to address known problems. By simulating the same patient through multiple clinical sites, key issues related to communication and transitions of care can be identified.

We utilized in situ progressive site simulation as a needs assessment for quality improvement in the care of critically ill children in our pediatric hospital, including transitions from ground transport to the ED, and from the ED to the PICU. Using a high-fidelity simulator, we simulated critically ill children through the various settings, using active staff and actual equipment in the clinical settings. We utilized a simulated EMR “playground,” simulated medications, and had inter-professional participation including physicians, nurses, unit clerks, ED techs, respiratory therapists, pharmacy, and radiology techs. Assessment of our simulation was performed in real time with direct observation by an inter-professional team, followed by a structured debriefing. A “no-go” or emergency cancellation policy was put in place to preclude the start or continuation of a simulation scenario in the event of excessive volume or acuity of actual patients.

Several opportunities for improvement were identified, including inconsistency between nursing and physician hand-offs, knowledge gaps among staff of the location of some crucial equipment, variability in adherence to transportation policies, and lack of a system for notification of arrival of a critical patient to the unit. Over 120 healthcare providers participated in the four different simulations we conducted. 

Using in situ simulation in a progressive site manner allowed for the study of patient safety vulnerabilities during transitions of care, which have been identified as high-risk situations. While in situ simulation can be resource and time intensive, it can help to uncover previously unknown issues in a healthcare system and consideration should be given to expanding


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