How often are you able to get out of your own Intensive Care Unit (ICU) to look at it from a distance – to solve problems, to improve efficiencies, or to reflect on past performance? Although each ICU may have its own unique culture and environment, most share the challenge of finding time to step away for the sake of quality improvement. 

The great news is that one of the most effective ways of stepping away is by not stepping away at all. It’s by replicating cases in your own ICU environment. This is what simulationists call in situ simulation. 

In situ simulation, simulation conducted in the actual patient care environment, has emerged as one of the most powerful tools to drive healthcare quality improvement.¹  

By bringing realistic, high-stakes simulation scenarios directly into the ICU, in situ simulation allows teams to test systems, uncover blind spots, and refine workflows before harm occurs.  

In this article, we explore four ways that in situ simulation can help ICU leadership, risk management, and quality management teams achieve their goals and ultimately improve patient safety. 

1. Uncover hidden risks before harm occurs. 

“Currently, we spend a lot of time looking at processes after an error. … The use of simulation [allows us] to explore proactively where these latent risks are living so that we can eradicate them before near-sentinel or sentinel events occur.” 

- Jennifer McCarthy, MAS, NRP, CHSE-A

Director of Clinical Simulation at

Seton Hall University and President/Founder, 579 Solutions

 

In situ simulation is a valuable resource for identifying latent safety threats, or “accidents waiting to happen.”³ 

Because in situ simulation takes place in the actual clinical setting, it can lend a unique opportunity to uncover latent safety threats involving your ICU’s own space, equipment, processes, and protocols before they ever reach a patient. 

In situ simulation can give your team the chance to “stress test” systems in real time, revealing latent safety threats like:  

• Medication safety issues 
• Protocol inefficiencies
• Equipment issues
• Teamwork and communication factors  

For example, a simulated sudden deterioration in the patient may test for medication errors and issues such as incorrect dosing or omissions in the prescribed dose. Or, that a delay in paging the on-call anesthesiologist adds precious minutes to airway management. Once uncovered, these findings can be addressed before a real patient is at risk. 

2. Improve team communication under pressure. 

Research shows that breakdowns in communication among critical care teams are a major contributor to adverse events.⁴ 

The ICU is its own unique environment and culture – with providers caring for uniquely unstable patients. This necessitates a level of teamwork and communication that must be second nature for ICU teams to maximize their effectiveness. Breakdowns in communication can be catastrophic, whether it’s an incorrect medication order, a delayed intubation, or an unclear handoff.  

In situ simulation allows multidisciplinary teams to practice critical interactions during ICU emergencies, from anesthesia complications to rapid deterioration from sepsis. 

By simulating (and effectively debriefing) these high-stakes moments, teams can work on developing shared mental models, clear role definitions, and an instinct for concise, precise communication.  

In situ simulation in the ICU has been found to improve communication during patient transfers and emergency situations. It has also been shown to foster a more positive attitude toward the culture of safety.⁵

“We all know to err is human. We know that getting teams together to practice high-risk situations, and being able to talk about it afterwards, can really help build patterns for the teams to bring into their practice. … to really impact healthcare quality and improvement beyond the individual silo level.”

- Lisa Brown, RN, MSN, CHSE

Senior Simulation Education Specialist at Cleveland Clinic 

 

3. Generate data that can fuel improvement. 

Quality improvement thrives on meaningful data. In situ simulation produces rich, actionable information about how your ICU actually functions under stress – from time-to-intervention metrics to medication error rates during emergencies. 

In situ simulation provides data on metrics such as: 

• Time to intervention (e.g., how quickly did the team act during a sepsis event?)
• Protocol compliance (e.g., did the team follow best practices for Ventilator-Associated Pneumonia (VAP) prevention or medication administration?)
• Medication administration (e.g., were there delays or errors in administering critical medications?) 

Once identified, this data can become the starting point for targeted process changes. 

4. Test and refine protocols before full implementation. 

Even the best-designed protocols can fail under the realities of ICU care – especially in high-pressure scenarios such as managing sepsis or responding to pulmonary embolism.  

The importance of in situ simulation is that it allows you to test any improvements in your own real environment before putting those improvements into place. In an environment where patients are inherently at risk, simulation affords you the opportunity to simulate any action before ever implementing improvements on a live patient. 

This approach minimizes risk, gives you objective patient data, ensures protocols are practical and efficient, and increases staff confidence in executing them correctly. 

We’re doing some exciting things in the field of Healthcare Quality Improvement. Follow our Healthcare Quality Improvement hub page for more resources.