Episode 05: In conversation with Dr. Andrew Petrosoniak
Dr. Petrosoniak describes the exciting ways in situ simulation can be used to replicate systems and processes and test new ideas and equipment – all with the goal of improving patient safety.
Today, your host Ellen Gardner, Communications and Marketing at HIROC, speaks with Dr. Andrew Petrosoniak, Emergency Physician and Trauma Team Leader at St. Michael’s Hospital.
When people come into emergency it’s often the worst day of their lives. For emergency physician and trauma team leader Dr. Andrew Petrosoniak, that’s what makes trauma care interesting and rewarding. He energizes teams and has built an international reputation around the value of in situ simulation as a quality improvement tool. Watching how people perform their jobs in the real work space and getting feedback enables Petrosoniak and his team to identify the latent safety threats and make changes before the patient ever arrives.
Ellen Gardner: Good afternoon. I'm Ellen Gardner. I work in marketing and communications at HIROC. And today we have a good fortune of talking with Dr. Andrew Petrosoniak, an emergency and trauma physician at St. Michael's Hospital in Toronto. Welcome Andrew.
Andrew Petrosoniak: Thanks for having me.
Ellen Gardner: Good to be here. What were your early years like Andrew?
Andrew Petrosoniak: So, I grew up in a small town in Ontario, and I think my attraction to healthcare came from my parents who are both in healthcare. My mom's a physiotherapist and my dad's a family doctor. So, around the table at dinner we would often hear them talking about their days and it would involve patients and things like that. So, it seemed like a natural thing and that's where I think I got my interest and I knew from probably pretty early on that I was going be a physician.
Ellen Gardner: Then why emergency medicine?
Andrew Petrosoniak: I didn't really know what I wanted to do. When I first got into medical school, I thought maybe I'd want to be an infectious disease doctor, and I thought it was very interesting stuff. But once I did my emergency medicine electives, I had a mentor, Dr. Janet Newth, and she was just so passionate about the specialty and really was an excellent educator. She was a wonderful person and that was probably the biggest initial reason that I became interested in it.
And then once I started doing electives and my core rotations, I just loved the diversity that we could really focus on initial resuscitations, help people when they need it most. Oftentimes when people visit the emergency department it's probably their worst day. And so being a part of that was certainly interesting and rewarding. I didn't think that I wanted to be such a specialist in one kind of particular field. I enjoyed all aspects.
Then I started to get interested in trauma care, and emergency medicine offers that as well. So, it was a combination of things that really led me towards emergency medicine.
Ellen Gardner: You really can say that emergency medicine and trauma care are team sports in the truest sense. It's not the same as other kinds of medicine where it's only a one-on-one kind of situation. You actually talked about that in your writings and your papers. And in one of the papers I read you talk about the components that go into making an effective team in emergency. So, when a team is working really well Andrew, what is going on?
Andrew Petrosoniak: There is a really a shared mental model of, "Here is what we need to achieve. Here's our end goal." We all know the small steps we each need to contribute to get to that end goal. And when each individual makes their small contribution, the whole team works quite well. It’s certainly an instance where the sum is greater than the individual parts, and then that result is often times quite high level performance.
Ellen Gardner: You work in one of the largest and busiest urban emergency departments and trauma centers in Canada. Have you ever worked in another kind of environment where you've seen different kinds of dynamic with the team?
Andrew Petrosoniak: Yes, so I had the amazing opportunity to work in New Zealand, in Auckland. I was a physician on the helicopters there. There we actually worked in a very small team where we knew everybody, we trained with the same few people every day. In Auckland, we had a couple of paramedics, we had a couple of pilots, a couple of crew men and then me, or the other physicians, and so that was a very different dynamic. You knew exactly what each other’s nuances were, what preferences and it made for certainly a high level of team performance.
And we see this within teams outside of medicine whether it be sports, or music or when you see a symphony perform, and you're always working with the same individuals. The implicit communication that can happen just knowing exactly how that person is going to perform, it might be a particular cue to you to do something and that stuff is very difficult to teach without just simply doing reps, going over and over, again and again. And that's something that is unique to, I think smaller teams.
Ellen Gardner: And you've, in fact, built a lot of your career and your reputation around in situ simulation. You talk about that as being the way to bring educators and quality improvement together. What was it that made you realize that simulation was a great way to go?
Andrew Petrosoniak: So, I think I've always been interested in education and as a side effect of that, or as a result of that, I became interested in simulation as one avenue to educate people better. And there's a reasonable amount of data to support simulation as an educational intervention, and it seems to work well. And I started getting interested in that with the goal of improving skill performance and human performance.
When I was in New Zealand and we were training in the work space, it became a little bit more apparent that there was value or opportunity to actually improve processes and systems in addition to education. So, not only would we train particular events like practising incubating patients, incubating the mannequins, putting in IVs, all of that kind of thing, we would also test out new ideas. If we were going to implement a new set of equipment, we would test that out in a real space and see how it worked.
And then I came back to Canada and we started looking at doing in situ stimulation for trauma care. And again it started mostly as an educational intervention and I thought, "Well, we can hopefully use this as a teaching opportunity. Why don't we actually take a step back, observe how teams work in their space and look for opportunities for improvement." And that's where this sort of quality improvement initiative and patient safety effort started to emerge. It became quite apparent that using simulation was a wonderful opportunity to inform subsequent educational interventions and also target opportunities for quality improvement.
Ellen Gardner: It would seem that in situ simulation would be difficult to do just because you're right in the space. I assume things are happening around you while you're doing it. How do you practically and realistically carve out that space and that time to make it happen? Is that a difficult thing to do?
Andrew Petrosoniak: Absolutely, yeah. And that's probably one of the reasons why you need to be precise with what the goals are. So, I can't simply go into the trauma bay every day and expect that we can get a team there, and have the trauma bay completely empty, and do training there. That’s just not feasible. So therefore, as an educational intervention, it's not quite as powerful. At least in my opinion.
The opportunity for education would lie with let's understand how the team works. Let's identify their deficiencies by watching them and then bring them to a sim lab later. That's where they can go through their reps and can focus and do deliberate practice the same way that a basketball player would just go to the gym and shoot free throws on their own.
So, what we would do would be when we wanted to run in situ simulation, we had a very prescribed checklist and approach to this, because as valuable as it is in that we were able to identify – without harming patients – problems that existed within the system or within the space, it can also harm a patient inadvertently.
We could inadvertently occupy beds that a patient needed emergently to be in. We could have overlap of equipment that somehow simulation equipment gets put into a set of real equipment. We could use equipment and forget to replace it.
All of these things need to be carefully considered when we're running in situ simulations. So, we had a whole team – when we'd first start, our team would go through the checklist, make sure that we had contacted everybody that needed to be notified to let them know that we were running a simulation, so that should anything, should they get called because we were using real phone lines, we were doing real pages that they knew that there was going to be a simulation happening.
We had to put up signs in the space so that patients who are in the waiting room would know that this is a training event. We would practice our set up and take down of the space. So, we would put up cameras, we'd put up microphones, we would bring in sometimes new equipment. But we would also then have a checklist and practice basically like a NASCAR or like a Formula One team in a pit crew where we would time ourselves. We’ve got be able to set up and take down within a few minutes because if a trauma comes in, then we need to be able to evacuate the space and let the real team take care of that patient.
Ellen Gardner: Through the in situ simulation, you were really shaking it up and changing the whole process of doing simulation. How did people respond to that? Was there a resistance to it? How did that go?
Andrew Petrosoniak: I mean, with anything that's new, there are going to be people that are early adopters, and late adopters. So, we certainly had a lot of people that were quite interested. Our leadership and administration were very interested because they saw the value in it. We make this very much about using or soliciting feedback from people how to make their workspace better. So, it is somewhat selfish initially on our part in that we ask something of them. But the idea is that we can hopefully garner support and then generate data to then inform change.
If you can somehow give people an opportunity to make change, and they can see that, then people will come around to that quite easily. But it does take some time. It takes some persistence.
You have to find some champions. So, we would look to certain people that we knew were early adopters from different specialties: nursing, respiratory therapies, other medical specialties within the hospital. And we also sought out not just clinicians, but people like our porters, our clericals, all of those people that make a team work every day. We brought them into the mix because we wanted to hear their feedback.
Ellen Gardner: The primary focus at HIROC is on patients' safety, improving patient safety, reducing adverse events – that's really our primary motivation. And it does seem with simulation that this is a way of teaching us how to improve patient safety. And when you say at the beginning that you do need that primary thing, a sense of urgency so have you seen that as a primary driver in simulation? That we're going to see improvements in patient safety if we move towards this model.
Andrew Petrosoniak: So, in one of the studies that we did where we were running regular in situ simulations, we looked at – where are the challenges in providing trauma care at our site. And one of the things that came up was our massive transfusion protocol and so we built simulation cases that included that. And before we made any changes, we just watched it happen. Our first challenge with our massive transfusion protocol was we were hearing from nurses that they didn't like how overwhelming it was to remember that they had to call two different places to get blood delivered to the trauma bay.
And just to give you a sense, a massive transfusion protocol is a way of rapidly delivering blood products to a bleeding patient. That needs to be done timely. Needs to be done quickly, and it needs to be done efficiently. So, the moment that it happens, the moment that the decision is made to proceed with what we call an MTP, or a Massive Transfusion Protocol, the nurse would activate and call for blood. But they had to call two places, they had to remember to call both blood bank, because blood bank would issue the blood, and they had to call locating, because that's where the porter services would come from. A porter would get paged and they would bring the blood to us.
You can imagine if you have somebody bleeding out in front of you, and all of the other things that are happening within a busy trauma bay to remember to make two calls instead of one sometimes doesn't get done. And so that memory lapse is not surprising. And so we heard from our nurses that they'd rather make one call. And we came up with an idea where we would make the call and you only call one place. And we would call only locating. And locating would automatically forward you on to blood blank. So, they were automating a process which is one of the best ways of making changes. And not forcing people to remember things.
When we ran this in simulation, we rolled it out in a simulated fashion before we did it in real life. And the very first time we did it, the calls dropped. And we were able to identify in simulation that our phone lines actually couldn't be forwarded on in the trauma bay. There is an inherent technical glitch that would have lasted probably many months before somebody finally said after many incident reports filed, "Hey, you know what? There's a problem." Instead people would probably just swear and complain about how locating keeps hanging up on them. And this is how things happen in the hospital.
So, unless you study it properly and identify and where the challenges are, often times they continue to exist on a regular basis. We've made a few other changes where we had porters were taking the elevators instead of the stairs and it's only one floor up, but they didn't know any different. They didn't know that they needed to get to the blood bank and back in a rapid manner, because nobody had really told them. They're non-clinicians. And so, when we ran this in simulation we asked them, "Why did it take you so long to get the blood, it's only two minutes away, or four minutes away?"
And they said, "Well, it was really busy on the elevators." That was a real eye-opening moment for me. And I thought, "Wow, I hadn't even thought of this. I didn't expect that would be a problem." This is a perfect example of a latent safety threat. Something that we hadn't even identified. And so we were able to go and educate the porters and now we have porters that come in, they announce themselves, they say, “Porter's here.” They feel they're validated in terms of identifying themselves. They know they're important members of the team.
And we've actually gone back and studied real patients now, and have we made any improvements in their time to blood delivery. So we've looked at before we made any of these changes, during, and then after, and we've seen in real patients, not simulated patients, but real patients, a reduction of about three minutes in time to blood delivery. And to give you a sense, for every minute delay, it's associated with about a five per cent increase of odds of death.
So, we're talking 15, 20 per cent reductions in odds of deaths that we're probably improving. So, we now get blood in under the nine minutes that we expect from what we were doing before which was around 12 minutes. So, we've really made some improvements and it's done by watching how people perform their jobs, identifying where the gaps are, making iterative changes over time, and then going back and studying those. And that's how quality improvement works – this is a perfect example of a PDSA cycle there.
Ellen Gardner: These are some of the real benefits of simulation. I bet there's even, beyond the patient care and patient safety, there's financial benefits as well?
Andrew Petrosoniak: Yes, there's a host of benefits. Certainly, traditionally the benefits exist within improving team and skill performance. And that's been studied over and over again. It seems that simulation is a better way of learning particularly for tasks that are hands-on or technical skills, than trying to teach somebody in a classroom. You can imagine if you were to teach somebody how to shoot a basketball you probably aren't going to pick a lecture as a way of teaching them that. You would instead bring them to a basketball court, give them a ball, put them in front of a net, and walk them through it.
And yet in medicine, at least historically, we would teach people all types of skills in a classroom. Now we've now shifted and we teach people in a sim lab, we teach them in the real space. We give them the equipment that they need, we walk them through it, and it does seem that's a better way of teaching people. Not surprisingly, the rest of industry and business and sports and music have all figured this out long ago.
We can replicate systems, processes, we can study physical spaces much better using simulation and not impact the patient and understand exactly how things will work before a patient ever arrives. You can imagine that no car company is ever going roll out a car that hasn't been crash tested. It's not sufficient to just drive it around the neighbourhood and say that it's safe. I mean that's certainly has to happen, but ultimately it needs to get crash tested. Needs to be put through a collision. And we're not going wait for a real person to get in that car for the company to sign off and say that it's safe. It's just simply too high risk.
So, in healthcare simulations it's the exact same process. We have an opportunity where we can basically crash test the system. We have a mannequin, maybe we have a standardized patient. Whatever it might be, but it's not a real patient. And that's the benefit of it, is that we can crash test the system, understand how it responds under stress, and then make changes if needed or congratulate ourselves that we've built a system that's actually going to hold up against some of those stresses.
The financial benefits, it's a difficult thing because it requires an upfront investment by the institution, by the program, or whoever is the one investing. And so, some of the early studies have looked at central line placements or any particular technical skills. So, for example, central lines are required to administer particular medications, give a lot of fluid, and they're placed in critically ill patients. And if done quickly and improperly, then you can actually introduce infection to those patients when they get it.
There's new studies now that have shown that if we teach people using simulators, they can abide by the checklist, the protocols much better, and that when they actually go and perform them on real patients, the likelihood they introduce infection goes down much considerably. And the overall catheter associated infections, or blood stream infections are reduced.
So, in certain instances, these training programs cost hundreds of thousands of dollars because you have to train a whole hospital, you have to buy simulators, it's a fairly robust undertaking. You have to maybe pay for people's time to go to the simulator. Whatever it might be.
And, yet when they go back and they look and see if we actually reduce five, 10, 20, 30 blood stream infections per week, month, a year in a hospital, that translates to shorter lengths of stay for patients. There's cost savings for that institution. And the savings are over about ten-fold. Yet the challenging part is somehow convincing the institutional leadership that’s a valuable upfront investment. For that return on investment they may have to wait a few years, but that it's actually warranted. And that's where we're starting to see additional studies being done. It's important work that people are doing.
Ellen Gardner: I wanted to talk to you Andrew about something that has become an important focus for you and that's design thinking. Like simulation, design thinking is an important way of improving patient care, improving our physical spaces. What was it that got you excited about design thinking?
Andrew Petrosoniak: So, I had the opportunity and I'm currently involved in some of the design for our new space at St. Mike's. We're building a new patient care tower. We've just built a new emergency department, and we're building a new trauma bay right now. As we started planning our simulations, it became pretty apparent that we actually needed to properly design the processes, the systems, the roles for people, and some of the smaller pieces of equipment to fit within this new space.
We didn't have a lot of time to run the simulations leading up to the launch. We only had a few days from the time that the builders handed over the space to us. So we needed to be as efficient as possible. So what that meant was we did a lot of back-end work where we would build prototypes of the space. We would bring people together, understand what their needs were, which is the first step of design thinking – empathizing with people, understanding what it is they need. We brought our nurses. We brought our respiratory therapists, physicians, porters, clericals all together around a table. We had a blueprint set out, and we started asking them, "Hey, here are our ideas for how the new space might work, but what we really want is your feedback on how this is going to work." And they gave us ideas. We built them in and then we would go to prototypes. We went into mock-ups of the patient care rooms.
So, St. Mike's built us mock-ups of our trauma bay, they built us a mock-up of an actual patient care room. And we started running simulations there so that we could make improvements even before we got into the final space. Because the complexity of the design simply didn't capture the nuances that the providers, the clinicians needed. For instance, where the sharps bin should be located within a room.
An architect wouldn't know necessarily where that should go – it simply just goes on the wall. But for a nurse or for a doctor, who is carrying the sharp and an agitated patient who might be coming towards them, you want to be able to get rid of that sharp, and you want to do it in the safest way possible as you're trying to exit the room. So, it became pretty clear that we needed to have our sharps bins as close to the door as possible, and with a nice exit strategy for us.
And that was something that wasn't well integrated in the initial design, it just was overlooked and that's okay. So, by running simulations we were able to come up with these ideas. And this design thinking approach where you first understand what people need, you come up with your learning objectives and then you start building prototypes and testing, is a really unique opportunity, or a unique approach to design that we don't do so much in healthcare but it's well done in tech, in business, really where it comes from.
So, if you can make this space work better for you, if you can reduce that emotional toll of poor design. When your computer crashes, or it's not working properly it really becomes emotionally charged in a negative way, and that's going to impact how patient care is delivered. It's already stressful enough. We don't need any more stress in our space. So, we need to absolutely design healthcare spaces so that people actually are feeling positive about it.
So then the only opportunity that there might be negativity there is just the inherent stress of taking care of sick patients.
Ellen Gardner: One of the things that we have certainly noticed is that you are a strong believer in collaboration amongst physicians, and physicians learning from each other. So, why do you think it's really important that physicians get active in their own organizations and be vital contributors on their teams?
Andrew Petrosoniak: I am a very big believer in bringing in perspectives from everybody involved in the space, or the work that you are doing, because as I already alluded to, when you ask people for their opinion, it's amazing what you get back. People have perspectives that we don't anticipate. Just like the porter who we asked, "How are you getting from the blood bank to the trauma bay?" "Well, I'm taking the elevator." I didn't expect that.
And when we ask people for their perspectives and they have unique experiences, then you can actually use those to build an informed change towards what we hope is better care for patients. In the design of a healthcare space it’s critical that you have everybody that works in that space involved to some degree in the design process. The whole design thinking paradigm of the very first step, the most critical part is empathizing and understanding with those end-users. And understanding exactly what they do.
So, if it's a physician-related process that you're trying to change, you have to involve the physicians and understand exactly what they do. But at the same time, I wouldn't ask a physician to go make change for nursing policy because that doesn't make any sense. Maybe there's a perspective the physician has to offer, but certainly it should also involve the nursing team and maybe the patients. And that's one of the other areas that until recently haven't asked for their perspectives.
We run simulations and we use standardized patients and we ask them for their perspectives when we run these simulations and it's amazing what we hear. Even though they're not real patients, they're lay people and they really get into the role, and they give us some very powerful feedback about either how well we're communicating, how poorly we're communicating, what they feel, stuff that we just otherwise wouldn't expect or think about. And so involving everybody that's part of a process – including the value of having patient feedback – is vitally important.
Ellen Gardner: Really want to thank you Andrew for speaking with us today. Your work, your ideas, your vision for change using simulation, using design thinking, it's something that is going to have huge impact. And it already is. So, thank you so much.
Andrew Petrosoniak: Well, thanks for having me. It was great talking to you today.