CAEP FEI | Trauma Resuscitation Using In Situ Simulation Team Training (TRUST) Study

In Education & Quality Improvement, Featured Education Innovations (FEI) by Andrew PetrosoniakLeave a Comment

Rob is a fourth year resident who is just walking out of the resuscitation bay after working with the team on a 45 year old man hit by a car. His attending staff asks him to think about areas where the resuscitation could have been improved. As Rob reflects on the experience, he wishes that there was a way to better analyze these events and find areas for improvement. 

Emergency medicine can often involve resuscitation and other high acuity, high stress events. Thus it is important to identify potential safety threats during these events so that we can work on improving outcomes. This Feature Educational Innovation (FEI), titled, “Trauma Resuscitation Using In Situ Simulation Team Training (TRUST) study: A novel approach to safety threat identification and high-performance team training,” was originally posted by the CAEP EWG FEI Team in 2017 and answers the question: “How can we use in situ simulation training to identify latent safety threats and better understand resuscitation ergonomics ? A PDF version is available.

Description of TRUST Study:

Trauma resuscitation requires a multidisciplinary team to perform at a high level within a dynamic, high-stakes environment. The unpredictable nature of trauma care increases the possibility for errors, often from underlying latent safety threats (LSTs). In-situ simulation (ISS) is a point-of-care training strategy that occurs within the patient care environment involving the actual healthcare team and provides an innovative approach to quality improvement, LST identification and team training. Using risk-informed ISS, critical events can be recreated providing an opportunity to explore and learn from past challenges that may impact patient safety and system processes.

The objective of this study was to pilot regular, multidisciplinary, unannounced ISS that will aid to:

1. identify latent safety threats

2. understand resuscitation ergonomics

3. evaluate team coordination and performance during high-stakes situations


The authors undertook a comprehensive engagement process with all stakeholders involved in trauma care. Simulation cases were derived from a review of adverse events and unexpected deaths. Human factors experts aided with the integration of system- and process-related elements into the case design. The authors then conducted unannounced ISS sessions that began with a trauma team activation. Scenarios used either a high-fidelity manikin or standardized patient. Semi-structured debriefing facilitated team-based discussion and opportunity for reflective practice with participant-driven LST identification to augment ethnographic observation and process mapping. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. Feasibility was measured by impact on ED workflow and interruptions of clinical care.

Results and Reflections

The authors recently completed the data collection portion of the study. The study from development to implementation represented a massive undertaking requiring widespread engagement from hospital administration, ground level providers and a large study team. These efforts resulted in the successful implementation of regular, high-quality ISS at a Level 1 trauma centre – at minimum, an effective proof of concept. The existing literature is sparse regarding similar efforts and this is likely, in part, due to the inherent challenges of integrating trauma and ISS:

• Bringing an ad hoc team together for regular training when they spend the rest of their day in other areas of the hospital

• The unpredictability of trauma care, requires that the authors  delay or cancel sessions when a real patient requires care

• The integration of ISS when it is not yet part of the institutional culture, mandates considerable efforts to positively affect change

Employing key change management strategies, outlined by Kotter, was essential for the study’s success. This study also allowed us to apply a novel approach to LST identification. Until now, most studies using ISS for LST identification relied on participant feedback or video review at the discretion of the researchers. The authors  applied a novel human factors approach (i.e., framework analysis) to perform a deep dive into the potential areas of risk to patients. In addition, the authors  developed a novel tracking tool that can be quickly used to study team workflows, highlight high traffic areas, engage participants and investigate different team behaviours (figure 1). Much of the data analysis was performed by human factors experts (HumanEra) with whom the authors partnered throughout the study. This unique partnership was a key element leading to the innovations (both framework analysis and tracking tool) developed during the study.

The data from this study has helped inform changes across several domains:

• Modifications to our high-stakes processes (e.g., massive transfusion protocol)

• Ergonomic optimization of existing equipment, workspace and workflows

• Identification of areas for subsequent educational efforts and increased staffing to enhance trauma team performance

• Integration of findings into the design of a new ED space and infrastructure

Bottom Line

In-situ simulation represents a unique and effective training strategy to target both educational and quality improvement efforts, particularly in high-stakes environments. Future studies should investigate the impact of regular ISS on patient oriented outcomes.1


More about CAEP FEI

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.



Fan M, Petrosoniak A, Pinkney S, et al. Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST). BMJ Open. 2016;6(11):e013683. [PubMed]

Andrew Petrosoniak

Emergency Physician & Trauma Team Leader. St Michael's Hospital, Toronto, Canada. Interested in both simulation & social media. #FOAMed supporter.

Chirag Bhat

Chirag Bhat is an Emergency Medicine resident at the University of Ottawa. He has interests in medical education and toxicology. He is a basketball fan and cheers for the Toronto Raptors.