Good afternoon, how are y'all doing? And I'm keeping you from the Dallas and Niners game. My name is Kiran Habbar. I am tasked with talking about training in resuscitation and cardiac arrest. And I'll spend my talk on talking about the framework we've used and probably touch on some of the same points that Maya and Heather have just a bit. I am the Medical Director of the State of System Safety at Children's as well as the Simulation Director. And so a lot of this falls into my wheelhouse, so to speak. So let's get going. I have nothing to disclose. So I'm gonna present our institutional approach around training for cardiac arrest, what that framework is in terms of stepping back and thinking more about process and systems-based orientation to that. And then we can have a discussion around things from there. We have a unique system. I'm kind of tasked with developing systems both in the emergency room as well as both PICUs. And so I've been able to see the difference of different work systems. And so I'm gonna touch base on that a fair amount. All right, so here's what we're gonna walk through as an overview. SEAPs, which many of you may be familiar with and I will explain a little bit more, discuss more, kind of figuring out what your targets are. Because that's gonna vary for all of us. It just can't be the same institution to institution at moment to moment. Defining the work system, which is connecting really to SEAPs. And 80% of the time, what's happening? Not all the time, we can't do that. But for the most part, what is it that we feel we're seeing or experiencing? Simulation-based clinical systems testing and how we pair that with FMEA to do translational work and really focus in on process. And then ergonomics, which is a lot of what happens in the work system anyway. Okay, so overall, Children's Healthcare of Atlanta, we're pretty big, we got three hospitals. And we started really getting the team training into 2015. And what we were looking at really were non-technical skills. I wasn't really worried about teaching people PALS at these sessions, but it was really about role clarity, situational awareness within the arrest, sharing your mental model, et cetera. And we did see clinical training scores, team scores rather, and we were able to essentially get that into practice, where it was sustained for real events, because we were going around scoring people prior to this intervention and then after the intervention as well. And surprisingly, it stuck, because there was a lot of pushback to begin with. In 2018, I did some hospital design work where I used the SEAPS framework. And so we really got to thinking, God, there's gotta be a better way to really put process around how we train our people. Because it still seemed very scattered. It was very reactive to what was happening in the moment. And in the last few years, we're no longer just updating our cardiac arrest guidelines every 10 years. There's always something to pivot on. There's the pandemic. So we have to have fewer people in the room. There's those aerosol generating particles. God forbid we talk about those again, right? And then feedback devices. Where do they sit at the table? And how do you now fit a CPR coach in for institutions that are doing that? Because that's another person on your team that's taken up valuable real estate. And sometimes a five kilo kid. And so it's really important to figure out where these things go ahead of time. And so my fellow Elissa Gallican talked about this this morning. And so I'm gonna pick up the kind of story with our twist, which is our translational work, integrating simulation and safety as well as systems testing. And really this is a way to diagnose as well as provide real-time interventions. And I'm not suggesting this is gonna be a protracted or long process. We do a lot of this at the bedside in real time. Kind of quick and dirty, if you will. When I did design testing, it was really prolonged when we were designing a hospital as it needed to be. But I think this is one way that we can effectively do this quickly at the bedside. We've done this successfully in the ED emergency room and we are doing a study right now in our PICU. All right, so the elements that go into twist essentially are we've got to do an in situ sim to begin with, okay? And I'll talk about why in a second. Then we layer in this clinical systems testing at a separate session and do debriefing at that time. That debriefing is paired with an FMEA. And I'll talk about why I think that's important. I understand the limitations of FMEA. And then where do we put those system improvements, okay? So the SEAPS framework is something I use all the time. There's a 3.0 now, which is a little bit different. We're still catching up. So we're gonna get this under control. But we really look at everything within the work system. Our goal is we gotta define what our work system looks like. If I look at our two hospitals and the two PICUs, the work system is very different in both because all the elements are different. They're structured differently, even the equipment's different and the environment is very different as well. Those rooms are just not the same. Then we go to the ER and it just can't be the same. So the prescription we give for how we're gonna run an arrest is gonna be highly variable. Because all those elements in the work system give way to our process. And so that tells us ahead of time process can't be the same. Sometimes I have administrators come to me and say, well, this worked at this hospital at Eggleston. We're gonna do the exact same thing at Scottish Rite. And that just doesn't translate. And we see it time and time again. And it's like hitting your head against the wall, okay? So this hopefully gives us the framework to help provide the argument and move past that. I think upfront, before you move into training, you need to have a sense of what are your broad targets? Is there something else that Bobby and Vinay have found at CHOP that we need to start chasing from a physiologic target standpoint? Diastolic blood pressures, end tidal, chest compression fraction. Are you going after that or are you going after non-technical skills? I am very biased. I feel the non-technical skills are really what make the orchestra, the symphony of the cardiac arrest work. You can't do the physiologic variables well if you don't have things orchestrated well. And all the things I've listed below there are elements that we've used this approach for. All right, so we've added that first sim. We're gonna bring mostly frontline staff to, not a ton of leaders to begin with. And we wanna really get into the work as done versus work as imagined paradigm, okay? This really helps close the gap around perception. If you're in a certain discipline, you could be an RN, an RT, an MD, get a little bit of tunnel vision around what you think is important, what you think is happening during events. And that pans out during debriefings. When you're doing an actual sim, you've got real-time evidence to go back and say, that's actually not what was happening. And for example, there's a time warp during an arrest. Every 10 seconds, a doc was asking for drugs from nurses. Where are my drugs? Where are my drugs, intubate? Where are my drugs? Where's my epi? Well, it takes time to get this stuff going. And the nurses need to be left alone so that they can actually do their job. So once we kind of codify what work as done really looks like, then that gives us a great baseline to move forward, okay? And then we layer in our clinical systems-based testing. And so this is a separate session. We bring leaders here, operations people. We need people that help drive how operations are gonna work along with frontline workers, okay? This is a proactive means. If we're talking about safety, safety is an emergent property of a system, okay? So we have to do active work to really tease it out and be able to identify it. It's tough to just look at a room, think back on something and realize that. And then we're gonna look at that work system in that particular environment or space and say, how does this work? So what are the latent safety threats? I think we've all three of us have kind of touched on this that you wanna tease out. And then what are the processes that you can do to help mitigate them moving forward, okay? So the more realistic this sim is, the better you're gonna be, okay? The better we feel it's gonna be at least. And then we pair that with an FMEA or failure modes effects analysis, okay? And so this gives us some way to semi-objectively go through and rate things. We essentially look at the severity and also the occurrence of how often something takes place. Right there, we can get a criticality number. If we're digging further and we wanna know, well, can I really identify this as a problem or is it really tough to identify? Then we add detection and get an RPI in there or risk priority index, okay? And at the end of it, we'll wind up scoring them and saying, okay, well, we need to address the red items or the higher priority items, so to speak. So that rubric over there looks at staff safety, patient safety is the primary one at the top, some regulatory pieces that may be there at the bottom as well. The example I've circled there, this is an ergonomic session with our cardiac group and people are all wondering where is that zone gonna go and where's that coach gonna be, okay? Because, and they have an open bay and a very differently constructed, it's not a room-based work. So right away, we have some work to do. And so we've been really talking about human factors and ergonomics, essentially, right? That work system and how those pieces interact is all human factors work, essentially. So we're looking at the physical environment, also the cognitive load on people as well, and how they all interact within that workspace, okay? So it's a very different type of sim. I know I haven't talked a lot about doing chest compressions yet, but I think until you can codify what your process is gonna be, you can't get to that point and do it well, okay? All right, so no two units are alike. We kind of talked about this. These are two, these are, one is a rest in the ED. Another one is a cross-campus PICU at Scottish Rite. And the environment alone is, that one on the right especially is a little constraining. So it gives me the creeps, so. But we're gonna have to do things different in there and we don't have as many people to run the arrest at other institution. All right, so some of the things that we found doing through this are inefficient supply allocation, where people are positioned. And so where people are positioned became a really big one and led to us room mapping, okay? So we try, as part of our mitigation strategy, just like Maya has, but not quite as cool and not quite as neat, is we have these maps on the doors to essentially help us. And I'll put a picture of that essentially. If you've got a high-risk patient, we have a hotspot or a watcher program as well. We really wanna emphasize people do room mapping up front so that you've thought through what it's gonna be like to run this arrest. And getting everyone to do that is hard, right? So, because it requires some patience. You've gotta be willing to spend time on rounds. But I always tell people, you're not gonna have more than three or four watchers necessarily in your unit. People, patients that you think are gonna have a cardiac arrest. And so you really just need to do it on a very small number of patients. With the turnover at the bedside as well with our nursing staff, I feel it's a great educational opportunity as well. We have our doc squad, which is the documenter plus the doc, essentially, at the head, and a med prep area. And then the other things we added were a pharmacy cart and a defibrillator cart, which I'll show in a second. Here's our map, essentially, that I just laid out. So this is part of our risk mitigation. When put in play, it works very well. When not, it's just another thing hanging on the door. It's like another random sign. So we have them outside every room door. And I would say that our fellows are really good about doing it, so kudos to you all. This pharmacy cart actually is flat and then breaks open. And so one of our issues with getting pharmacists into rooms, having them in the hall with that was just not working. They only need one tray from our code cart. They'll come in, now that cart is actually flat. It opens up in the back, and we have a spot where drugs are drawn within the room itself. And then that little tray over there, there were drugs all over the place. And so it helps, essentially, keep it organized. And a lot of ICU folks tend to be organized and neat, so it helps. All right, once we do that, we hardwire it. And we hardwire it through training. So the team training that Hila alluded to this morning, we'll put in place using rapid cycle deliberate practice. And I'm a big proponent of rapid cycle for non-technical skills. We did a NASA TLX study. We have a paper kind of in process right now looking at the cognitive load on the facilitator as well as the learner. And they were both significantly lower for using rapid cycle versus traditional reflective debriefing, right? And the other thing is, practice is one thing, but perfectly practicing is really where you're gonna make your difference. And if you do a TRD, a traditional reflective debrief, that's one round, and you're done. And so it's really hard to walk away feeling a sense of mastery that you've repeated something to that point. These are our references. And then some acknowledgments. This has been going on for a long time, so I got some old fellows up there. Mark Dugan, Jordan Newman, if you're here. And then Ila, of course, and then Nora Coleman. I don't know where I'd be without her. Okay? And there we go.

resuscitation

non-technical skills

SEAPS framework

simulation-based testing

rapid-cycle practice