Human factors
and cues, which will enhance the simulation.11 On the day in question, all teams were briefed and presented their scenarios. A final run through for the whole department took place, which made sure that clear notices for areas outside of the exercise and pathways for non-elective patients remained intact. The team then reported to the neighbouring short stay surgery ward to confirm with the ward manager that it was appropriate to start and that all patients remaining in the ward were dischargeable and waiting for a relative/friend to pick them up. This ensured that the noise and actions that could be made during the exercise, did not affect any patient’s health or treatment. The team also spoke to each patient still on the ward to inform them about the exercise, so that they were aware and not put into any distress on hearing alarms or seeing smoke/emergency rescue teams. All further reference to ‘patients’ were simulated by mannequins or staff acting in the role.
Once confirmation that all patients from Scenario Scenario 1 TH 1 A child was being intubated for an
elective tonsillectomy at the time the fire alarm goes off
Scenario 2 TH2
A female was undergoing a laparoscopic hysterectomy which had converted to an open hysterectomy. The patient had an uncontrolled haemorrhage which was slowing down
Scenario 3 TH 3
A male patient was nearing the end of surgery. The fire is directly outside of this theatre.
Scenario 4 TH 4
A patient was undergoing an emergency tracheostomy.
Scenario 5 TH 5
A bariatric patient was undergoing an ORIF of Ankle under spinal anaesthetic. Due to medical conditions, the patient cannot have a General Anaesthetic.
the morning lists had left the department, the smoke machine was activated, and a fire alarm was broken in the location of the fire. The initial Trust fire team – consisting of the clinical site manager (CSM), a member of the portering and estates and facility team – identified it was not a false alarm by visual evidence of smoke in the internal corridor and reported back to the clinical site team that it was not an accidental alarm. As part of the Trust fire response plan, it is the responsibility of the clinical site manager to respond to all fire alarms alongside security who bring a fire bag containing essential equipment and site maps. Supported by a member of the estates department, the clinical site manager decides to either stand down as a false alarm or call 999 for fire service response, and to take the necessary actions to ensure all patients and staff are safe. As part of this scenario, the clinical site manager made the decision to ring 999 and ask for a response from the fire service as per Trust policy.
Aim
The scenario is designed to test both communications with the perioperative, site and fire teams regarding the best
course of action; to wake the patient up and transfer to a site of safety.
The scenario was designed to test the theatre team’s response to having to assess the clinical need of the patient, continuation of surgery until appropriate evacuation equipment was available and an appropriate area and route to continue open surgery
The scenario tested the human
response to immediate danger and the coordination of evacuation when an imminent danger is present.
This scenario was to test the cannot evacuate procedure due to the clinical
emergency. Communication and hierarchal command was engineered to be challenged.
This scenario was designed to test two responses. The first, how to evacuate a bariatric patient. This was engineered as the route for evacuation was expected to
be obstructed with KFRS equipment. The second response was due to chronic airway medical conditions, how to avoid further complications linked with potential smoke inhalation.
Table 2. Clinical Scenarios This had been agreed with CFRS, as they were
keen to test their initial response and, although they had made provisions for cover of services, while the exercise was being undertaken, their fire crews were given no further information. Lame and Dixon-Woods9
describe that
enhancing fidelity, by not informing all parties about the scenarios planned, allows the faculty who have developed the programme to observe the real-world reactions and behaviours, and to reflect and respond to issues that are raised through observation and evaluation, in a safe and controlled manner. This is particularly useful in testing rare situations, such as a major fire in a hospital, but also increases the validity of the whole experience, which allows for the multi- agencies to self-reflect on their own responses to the scenario. The incident control centre (ICC) was established with a tactical commander from the Trust, police, ambulance, and fire service also working under JESIP principles. From the Trust perspective, the CSM at the bridgehead was the conduit of information to the ICC. With the Trust tactical commander working alongside blue light services, they were able to address the situation relating to capacity, staffing, welfare, resources, and to ask for assistance where needed. This helps develop ideas around what the plan would be if they needed to move patients off site, what assistance the other services could offer to not only transport these patients, but also to get them to a safe area to transport from. Throughout the exercise, staff involved in
each of the scenarios were encouraged to act out, as prompted, and allow the scenario to evolve as decisions were being made by those inside theatres and by the clinical site manager. Observers were present to help with interjections, if the scenario was deviating away from the primary objective, so that the aim of each scenario could be appropriately tested. Several scenarios were engineered to deteriorate throughout the exercise with one planned (scenario 9) to be identified as ‘deceased’ on discovery. With other scenarios, such as scenario 7,
the actor playing the role of the patient was encouraged to demonstrate signs of respiratory arrest, if they felt that the staff were being overly distracted by other ongoing actions. If there was no further action or help, then the patient was engineered to ‘pass away.’ This would enable further opportunities for learning, with the ability to host future learning exercises on public enquiries based on the initial live fire exercise and the response and decisions undertaken. The exercise event was successful. Learning
July 2023 I
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