Traditional Poster Round
Context: : The 22-bed Pediatric Emergency Department (PED) identified an opportunity to improve the efficiency of the process for releasing emergency blood after a delay during a pediatric trauma. A physician and nursing leadership from the PED collaborated with key stakeholders from the blood bank, quality and safety, patient registration, and risk management to improve the process for releasing emergency blood products. A new workflow was developed, and thereafter tested with in situ simulation in collaboration with the simulation team.
Description: : An interdisciplinary team created a pediatric trauma simulation involving a high-fidelity pediatric simulator. The first simulation followed by debriefing, took place in the PED trauma rooms. The participants were clinical staff working in the PED and blood bank at the time with no advanced notice. A job aide was created outlining the revised emergency blood product release workflow. Simulation participants were provided the job aide at the time of simulation. The objective was to test the usability of the job aide and efficiency of the new process. Following the first simulation, education was provided to all PED and blood bank staff on the job aide and new process. After the education, the same simulation scenario took place in the PED trauma room. Again, the participants were clinical staff working in the PED and blood bank at the time and no advanced notice was given. After the second simulation the simulation team compiled an after-action report (AAR) that summarized latent safety events that were identified and recommendations from observations and associate feedback during the debriefing session.
Observation/Evaluation: : During the simulation one latent safety event and opportunity for improvement was identified which included recommendations for process improvement. The simulation demonstrated the new process and decreased the amount of time it takes to obtain emergency blood available at the patient’s bedside.
Discussion: : Previously, the emergency release of blood products had taken on average 15 minutes to become available at the patient’s bedside. The newly developed process decreased the amount of time by approximately 70%, to just under five minutes.