PC3119: Discovering Latent Patient Safety Threats During the Implementation of High Frequency Ventilation on Neonatal Transport Through Simulation and Debriefing

Background: Specialized care of high-risk, critically ill neonates requires the adoption of new technology into clinical practice. High frequency ventilation (HFV) during neonatal transport allows for infants with the most severe cardio-pulmonary pathology to be safely transferred to higher levels of care for surgical, hemodynamic and pre-ECMO assessment. There is currently limited published reports on how to implement HFV on neonatal transport.

Methods: In the fall of 2020, our children’s transport team members were led through 3 short simulation scenarios involving HFV on transport by a neonatologist. The three scenarios involved: 1) initial transfer of a clinically ill neonate from a high frequency oscillating ventilator to the high frequency transport ventilator (HFTv), 2) making adjustments to the HFTv to optimize the neonate’s oxygenation, 3) making adjustments to the HFTv to optimize the neonate’s ventilation. Immediately following the completion of the scenarios, transport members were debriefed by the neonatologist. During the debrief, participants were specifically asked to comment on any complications or challenges noted in the setup and use of the HFTv during the scenarios. All learners attended at least one more subsequent simulation session where they led their colleagues through the scenarios and debriefing while being supervised by a neonatologist.

Results: Learners in the simulations included transport nurses (n=6) and transport respiratory therapists (n=13). A total of 13 simulation sessions were conducted over a 7 month period with 2-3 transport members attending each session. All transport team members participated in at least 2 sessions. During the debriefing sessions, 8 latent safety threats directly related to the HFTv were identified by the learners. These latent safety threats were highlighted in the subsequent simulations as the learners became teachers and led their colleagues through the scenarios. This sharing of potential safety threats led to process changes based on the learners’ experiences and suggestions. This led to the creation of a HFTv pocket guide by the transport team that was placed with each HFTv. Since the completion of the simulation training in the summer of 2021, the HFTv has been used successfully by our transport team on 3 critically ill, pre-ECMO transports.

Conclusion: The use of simulation to implement HFV on neonatal transport produced unexpected discoveries. During the debriefing sessions, transport team members uncovered eight latent patient safety threats. The identification of these threats allowed for the rapid introduction of corrective measures and team members to reach a high level of proficiency, confidence, and safety prior to the HFTv going into service. Additionally, the simulations highlighted the importance of shared-learning and collaboration. Without the shared expertise and knowledge from each field, the implementation of HFV in our neonatal transports would not have been successful.