In Situ Simulation – Part 2: ED in situ simulation for QI at Kelowna General Hospital

This 2 part series was written by Jared Baylis, JoAnne Slinn, and Kevin Clark. 

Jared Baylis (@baylis_jared) is a PGY-4 and chief resident at the Interior Site of UBC’s Emergency Medicine residency program (@KelownaEM). He has an interest in simulation, medical education, and administration/leadership and is currently a simulation fellow through the Centre of Excellence for Simulation Education and Innovation in Vancouver, BC and a MMEd student through Dundee University.

JoAnne Slinn is a Registered Nurse, with a background in emergency nursing, and the simulation nurse educator at the Pritchard Simulation Centre in Kelowna. She recently completed her Masters of Nursing and has CNA certification in emergency nursing.

Kevin Clark (@KClarkEM) is the Site/Program Director for the UBC Emergency Medicine program in Kelowna. He completed a master’s degree in education with a focus on simulation back in the day when high fidelity simulation was new and sim fellowships weren’t yet a thing.

Welcome back to part 2 of our series on in situ simulation for quality improvement! Check out last months’ post for a deeper dive into the literature behind this concept. In this post, we will outline the vision, structure, participants, results, and lessons learned in the implementation of our ED in situ simulation program at Kelowna General Hospital (KGH).  

The Vision

KGH is a tertiary care community hospital serving the interior region of British Columbia.  Our emergency department (ED) sees in excess of 85,000 patient visits per year.  In 2013, we became a University of British Columbia distributed site for training Royal College emergency medicine residents. With this program came a responsibility to increase the academic activities in the department both for education and for team building and quality improvement (QI). Our aim with the program was:

  1.     Improve interprofessional collaboration.
  2.     Improve resuscitation team communication
  3.     Develop resident resuscitation leadership skills.
  4.     Educate emergency department professionals on medical expertise related to resuscitation.
  5.     Identify and select two quality improvement action items that arise within each resuscitation scenario.
  6.     Assess and respond to each QI action item in the interest of better patient care.
  7.     Educate participants and other department staff with regards to each QI action item in an effort to change process and behaviors.

From a departmental QI standpoint, we applied the “SMART” framework; specific, measurable, attainable, realistic, and time based.¹ Our goal, as stated above, was to select two QI action items that came up during the debrief following our simulation. Our nurse educator group follows-up on each of these items and reports back to the local ED network, pharmacy, or the ED manager depending on which is seen as most appropriate for the particular QI issue. This ensures our model remains sustainable over time. Follow up emails are sent out to “close the loop” with attendees and department staff after each session. Learnings from the simulations are also presented to the local ED network to share with smaller sites that do not have simulation opportunities.

The Structure

Each session includes one to two scenarios where a “patient” with a critical illness is resuscitated by the team. Both adult and pediatric cases have been run using high fidelity simulators and a variety of resuscitation topics. The cases are run over a 90-minute time-period once per month immediately prior to our departmental meeting. This encourages attendance and participation. The timing of in situ simulation also coincides with our residency program’s academic day further increasing attendance and participation. The resuscitation/trauma room in the KGH ED is used for these sessions. The program has been well received and was highlighted on the local Global News Channel as a public display of our QI initiative.

ED in situ 1

ED in situ simulation at KGH

The session begins with a pre-brief that includes brief introductions, general objectives, confidentiality, fidelity contract, and an outline for the session. This is followed by an orientation to the simulator, monitors, and equipment in the room. The scenario is then begun with a pre-hospital notification, bedside handover by paramedics, and then emergency department care ending with decision on disposition. The scenario is run in real time to maximize realism in terms of the time it takes to draw up and administer medications etc. This is followed by a debriefing session that takes in feedback from all team members as well as observers. This is led by a staff physician with experience in simulation debriefing. CanMEDS themes such as communication, collaboration, leadership and medical expertise are all discussed.²

Participants and Recruitment

Participants include emergency physicians, residents, nurses, respiratory therapists, pharmacists, paramedics, security, and students from the aforementioned groups. Participants are recruited with an email announcing the session one week prior, sign up lists on the educators’ door, and posters placed in the ambulance bay and paramedic stations. Cases are determined by the EM Residency Director in conjunction with the Simulation Fellow, ED Nurse Educators, and the Simulation Nurse Educator. The cases are distributed to the discipline leads 2-7 days prior to the session in order to prepare students and newer professionals that may be joining.

Our Results

There were a total of 65 participants when the program began in 2015, with an average of 16 participants/session. This grew to 130 total participants and an average of 19 participants/session in 2016. There was a further increase in 2017 to 213 total participants with a session average of 24 participants giving a total of 408 participants since program inception. The distribution of participant disciplines over the duration of the program is below:

Graph 1: ED In Situ Participant Data 2015 – 2017

sim pic

Feedback has been informal, but overwhelmingly positive. The ED nurse educators have found in-situ simulation to be one of the most valuable educational experiences for the department and have advocated for the sessions to be paid education time for the nurses. This has increased buy-in and participation. Paramedics have commented that it is time well spent, that they appreciate seeing what happens to the patient after they hand over care. They also remarked that this type of training will go a long way towards better inter-agency cooperation and understanding.

A variety of QI initiatives have been brought forward from these sessions. This has included better use of existing protocols, finding equipment that is poorly placed or expired, and determining better team-working processes similar to what was described in our literature review. One specific example of our QI initiatives was the development of a simulation case around our pediatric diabetic ketoacidosis protocol (that was still in draft form), running the case using the protocol, and then providing feedback on revisions including clarity on initial fluid replacement orders, additions to the initial blood work orders, and improvements to insulin pump delivery. Further QI initiatives that have resulted from this project are summarized below.

Table 2: QI action items and their resulting actions

CATEGORY ACTION
Team/Communication

1.     Delay in call for help

2.     Team members not speaking up when change in patient condition noticed

3.     Medication order confusion between physician, pharmacy, and nursing

4.     Not all team members hearing report from paramedics

1.     Reinforce calling for help early

2.     Fostering an environment that encourages input from all team members

3.     Reinforce importance of using closed-loop communication with medication orders

4.     Reinforce one paramedic report where everyone stops and listens (unless actively involved in CPR)

Equipment/Resources

1.     Difficulty in looking up medication information in resus. bay

2.     Unsafe needles for use with agitated patients in resus bay

3.     Expired Blakemore tubes in ED

4.     Unsure of PPE needed during potential Carfentanil exposure case

1.     Installed additional computer in resus. bay in order to better access information

2.     Auto-retractable needles made available in resus. bay

3.     New Blakemore tubes ordered

4.     Communicated the provincial Medical Health Officer recommendations for Carfentanil PPE to staff

Knowledge/Task

1.     Lack of knowledge of local use of DOAC antidote

2.     Uncertain of local process for initiating ECMO in ED

3.     Conflict over when to intubate a hemodynamically unstable patient

1.     Reviewed indications/contraindications, ordering information, and administration of Praxbind (idarucizumab)

2.     Reviewed team placement, patient transfer, and initiation of ECMO line in ED

3.     Reinforced resuscitation prior to intubation

PPE – Personal Protective Equipment

DOAC – Direct-Acting Oral Anticoagulants

ECMO – Extracorporeal Membrane Oxygenation

Successes, Lessons Learned, and Suggestions

In this article, we set out to describe our experience with regard to ED based in situ simulation as well as to outline the evidence for in situ simulation as a QI tool (part 1). We hope that this serves as encouragement to those of you who are thinking of getting such a program started at your institution. In reflecting on our process, we would offer these suggestions and lessons learned:

  1. Engage a team. It takes a team that is committed to the process to get this off the ground. Take the evidence to your team, gain support, and then begin your program.
  2. Start out with your goals/aims/objectives in mind so that you know what it is you’re trying to accomplish.
  3. “Buy in” is key. Try to structure your program so that it is convenient and so that attendance and participation is encouraged. For us this meant holding our in situ simulation on academic days for the residency program and immediately preceding our departmental meeting.
  4. Celebrate your successes with everyone involved to build a culture that values in situ simulation and quality improvement.
  5. Bring team members on board who are trained and experienced in simulation as debriefing a multidisciplinary simulation can introduce specific challenges. This is beyond the scope of this article but there are many good resources out there on debriefing including the PEARLS framework.³

We’ll close with the 10 tips that Spurr et al. described in their excellent article on how to get started on in situ simulation in an ED or critical care setting.

  1. Think about your location and equipment    
  2. Engage departmental leaders to support simulation
  3. Agree on your learning objectives for participants and the department
  4. Be a multiprofessional simulation program
  5. Strive for realism
  6. Start simple, then get complex
  7. Ensure everyone knows the rules and feels safe
  8. Link what you find in simulation to your clinical governance system
  9. The debrief is important: be careful, skillful, and safe
  10. Be mindful of real patient safety and perception

We would love to hear from you. If you have any questions or comments please feel free to comment on this post or to reach us by twitter (@baylis_jared, @KClarkEM, @KelownaEM).

References:

  1. Haughey D. Smart Goals [Internet]. [cited Dec 2017]. https://www.projectsmart.co.uk/smart-goals.php
  2. CanMEDS: Better standards, better physicians, better care [Internet]. [cited Dec 2017]. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
  3. Eppich W, Cheng A. Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare. 2015 Apr 1;10(2):106-15.
  4. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+ 1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J. 2016 Jul 1;33(7):514-6.

In Situ Simulation – Part 1: Quality Improvement Through Simulation

This 2 part series was written by Jared Baylis, JoAnne Slinn, and Kevin Clark. Part 1 is a review of the literature around in situ simulation for quality improvement and part 2 will detail the emergency department in situ simulation program at Kelowna General Hospital including successes, lessons learned, and suggestions for those of you considering starting an in situ simulation program in your centre.

Jared Baylis (@baylis_jared) is a PGY-4 and the chief resident at the Interior Site of UBC’s Emergency Medicine residency program (@KelownaEM). He has an interest in simulation, medical education, and administration/leadership and is currently a simulation fellow through the Centre of Excellence for Simulation Education and Innovation in Vancouver, BC and a MMEd student through Dundee University.

JoAnne Slinn is a Registered Nurse, with a background in emergency nursing, and the simulation nurse educator at the Pritchard Simulation Centre in Kelowna. She recently completed her Masters of Nursing and has CNA certification in emergency nursing.

Kevin Clark (@KClarkEM) is the Site/Program Director for the UBC Emergency Medicine program in Kelowna. He completed a master’s degree in education with a focus on simulation back in the day when high fidelity simulation was new and sim fellowships weren’t yet a thing.  

In situ simulation is a team-based training technique conducted in actual patient care areas using equipment and supplies from that area with people from the care team. (1,2) There have been an increasing number of studies published since 2011, the majority being since 2015, investigating the benefits of in situ simulation as a quality improvement (QI) modality. (1-20) These studies offer a fascinating glimpse into the world of potential that exists within in situ simulation. Here is a quote by Spurr et al. that eloquently describes the potential benefits of in-situ simulation: (19)

“In situ training takes simulation into the workplace. It allows teams to test their effectiveness in a controlled manner, to train for rare events and to interrogate departmental and hospital processes in real time and in real locations. It may also allow teams to uncover latent safety threats in their work environment.”

In this article, we will review recent literature surrounding in situ simulation as a QI tool as a preface to part 2 (next month) where we will describe our process of starting and maintaining an emergency department (ED) based in situ simulation program.

How can in-situ simulation be used for QI?

In the healthcare setting, QI is typically seen as systematic actions that result in measurable positive effects in health care services and/or patient outcomes. (21) There are several ways that in situ simulation can lead to improvement, all of which fall under the umbrella of QI. Previous studies have identified these as improvements in individual provider and/or team performance, identification of latent safety threats (more on this later), and improvement of systems. (11) We will go through several specific examples in the literature which were found by performing a librarian assisted literature search with search terms “in-situ”, “simulation” OR “simulation based education”, “emergency medicine”, and “quality improvement”. The search yielded 39 records of which 19 were excluded for lack of relevance. This left 20 records which were reviewed. The main themes of quality improvement using in situ simulation are described below.

Crisis Resource Management

Simply put, crisis resource management (CRM) speaks to the non-technical skills needed for excellent teamwork. (22) These, according to Carne et al., include knowing your environment, anticipating, sharing, and reviewing the plan, ensuring leadership and role clarity, communicating effectively, calling for help early, allocating attention wisely, and distributing the workload. (22)

Wheeler et al. ran standardized simulation scenarios twice per month on their inpatient hospital units. (1) The units were involved on a rotating basis which provided each unit with at least two in situ simulations per year. They noted 134 safety threats and knowledge gaps over the course of the 21-month study. These led to modification of systems but also provided a means to reinforce the use of assertive statements, role clarity, frequent updates regarding the plan, development of a shared mental model, and overcoming of authority gradients between team members.

Miller et al. had a similar CRM idea in mind with their observational study looking at actual trauma team activation during four different phases. (9) Phase one was pre-intervention, phase two was during a didactic-only intervention, phase three was during an in situ simulation intervention, and phase four was a post-intervention phase. They noted that the mean and median Clinical Teamwork Scale ratings for trauma team activations were highest during the in situ phase. Interestingly though, the scores returned to pre-intervention levels during the post-intervention phase implying that any sustained improvement in teamwork (CRM) is contingent on ongoing regular departmental in situ simulation.

Several other studies had a CRM focus in their research involving in situ simulation and all of them either demonstrated improvement in CRM capabilities or identified CRM issues that could be acted on later as a result of in situ simulation. (10-11, 13-14)

Rare Procedures

The most recent example of using in situ simulation for rare procedure assessment comes from a 2017 publication by Petrosoniak et al. (20) In this study, 20 emergency medicine residents were pretested for baseline proficiency at cricothyroidotomy. Following this, they were exposed to a two-part curriculum involving a didactic session followed by a task trainer session. The residents were then tested afterwards by an unannounced in situ simulation involving cricothyroidotomy while on shift in the emergency department. The mean performance time for cricothyroidotomy decreased by 59 seconds (p < 0.0001) after the two-part curriculum and the global rating scales improved significantly as well. This suggests that in situ simulation can be an effective way of assessing proficiency with rare procedures in the emergency department.  

Task Trainer 1

Task trainers such as this chest tube mannequin can be used to teach a procedure before assessing proficiency using in situ simulation

Latent Safety Threats

Latent safety threats can be thought of as “accidents waiting to happen”. (1) There is mounting evidence that multidisciplinary in situ simulation can identify latent safety threats and even reduce patient safety events. Patterson et al. found that after introducing standardized multidisciplinary in situ simulation to their large pediatric emergency department, they had a reduction in patient safety events from an average of 2-3 per year down to more than one thousand days without a patient safety event. (8) The same author group noted that their in situ simulation program itself was able to detect an average of 1 patient safety event per 1.2 in situ simulations consisting of a 10 minute scenario followed by a 10 minute debrief. (10) These latent safety threats were a mix of equipment failure and knowledge gaps regarding roles.

Petrosoniak et al. noted that, with rare procedures, it is not adequate to just teach an individual how to perform the procedure. (11) One must rather run the scenario in an in situ simulation setting to identify potential latent safety threats as well as other systems and teamwork related issues. (11)

An interesting point of view was highlighted by Zimmerman et al. who raised the idea that demonstrated improvements in patient safety through the use of in situ simulation can be used to justify the existence of an in situ program from an administrative standpoint. (14)

Overall, in situ simulation is better at detecting latent safety threats than traditional lab based simulation and it can improve patient safety without exposing patients to harm and with increased realism over lab based simulation. (16-18)

Systems Issues (e.g. equipment, stocking, labelling)

Systems issues have a lot of overlap with identification of latent safety threats, teamwork, and CRM. However, one notable study is worth reviewing here. Moreira et al. conducted a prospective, block randomized, crossover study in a simulated pediatric arrest scenario comparing use of prefilled, colour coded (by Broselow category) medication syringes with conventional drug administration. (5) They demonstrated compelling results showing that time to drug administration was reduced from 47 seconds in the control group to 19 seconds in the colour coded group. Notably there were 20 critical dosing errors in the control group compared to 0 in the colour coded group.

Testing Adherence to Guidelines

Traditionally, adherence to guidelines is measured by chart review or survey of healthcare practitioners with regard to their practice patterns. Two innovative studies recently considered in situ simulation as a way of assessing adherence to guidelines. Qian et al. ran an observational study at three tertiary care hospitals that see pediatric patients. (4) They introduced a simulation scenario at one of the centres and then compared, post simulation, adherence to their sepsis resuscitation checklist and found that compliance with the checklist was 61.7% in the hospital that ran simulation compared with 23.1% in the two hospitals that did not have simulation (p<0.01). (4) Kessler et al. used standardized in situ simulations to measure and compare adherence to pediatric sepsis guidelines in a series of emergency departments. (7) They did not test simulation as a means of increasing adherence to guidelines but rather used in situ simulation as a tool to determine their baseline adherence rates.

Assessing Readiness for Pediatric Patients and Disaster Preparedness

In many centres, acutely ill pediatric patients are, fortunately, a rarity. Abulebda et al. measured the Pediatric Readiness Score (PRS) pre- and post-implementation of an improvement program that included in situ simulations in a multidisciplinary (MD, RN, RT) emergency department setting. (3) They demonstrated an increase in PRS scores from 58.4 to 74.7 (p = 0.009). This suggests that in situ simulation can be effectively used to prepare emergency department care team for receipt of patient populations that may not be the norm for any given centre.

This can be extended to disaster preparation as well. Jung et al. described how high influxes of patients to the emergency department during disasters can contribute to increased medical errors and poorer patient outcomes. (6) They found that in situ simulation can improve communication as well as knowledge in disaster situations.

Testing New Facilities Prior to Opening

John Kotter outlined an 8 step process for leading change initiatives in his book Leading Change. (23) Step 5 is to “enable action by removing barriers”. (23) This involves removing barriers like inefficient processes and breaking down hierarchies so that work can occur across silos to generate an impact. (23) For anyone that has worked in a facility that has undergone a major renovation, or even an entirely new build, you will have experienced some of the inefficiencies and issues that surface. In situ simulation may provide a medium through which to discover these inefficiencies and to test new facilities before they open for regular use.

Geis et al. completed an observational study that used a series of in situ simulations to test a new satellite hospital and pediatric ED. (16) They had 81 participants (MD, RN, RT, EMS) involved in 24 in situ simulations over 3 months. They identified 37 latent safety threats of which 32 could be rectified prior to the building opening for regular use. These included equipment issues such as insufficient oxygen supply to resuscitate more than one patient at a time, resource concerns such as room layout preventing access by EMS and observation unit beds not fitting through resuscitation room doors, medication issues such as inadequate medication stations, and personnel concerns such as insufficient nursing staff to draw up meds.

Summary & What’s Next?

As you can see there are many useful quality improvement processes that can come directly from a robust ED in situ simulation program. It often takes well defined goals and objectives as well as institutional buy-in to run a successful in situ simulation program. With that in mind, look out for our next post which will detail our emergency department in situ simulation program at the Kelowna General Hospital including aims, structure, participants, results, and lessons learned!

We would love to hear from you. If you have any questions or comments please feel free to comment on this post or to reach us by twitter (@baylis_jared, @KClarkEM, @KelownaEM).

 

References:

  1. Wheeler DS, Geis G, Mack EH, LeMaster T, Patterson MD. High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training. BMJ Qual Saf. 2013 Feb 1:bmjqs-2012.
  2. Yajamanyam PK, Sohi D. In situ simulation as a quality improvement initiative. Archives of Disease in Childhood-Education and Practice. 2015 Jun 1;100(3):162-3.
  3. Abulebda K, Lutfi R, Whitfill T, Abu‐Sultaneh S, Leeper KJ, Weinstein E, Auerbach MA. A collaborative in‐situ simulation‐based pediatric readiness improvement program for community emergency departments. Academic Emergency Medicine. 2017 Oct 4.
  4. Qian J, Wang Y, Zhang Y, Zhu X, Rong Q, Wei H. A Survey of the first-hour basic care tasks of severe sepsis and septic shock in pediatric patients and an evaluation of medical simulation on improving the compliance of the tasks. The Journal of emergency medicine. 2016 Feb 29;50(2):239-45.
  5. Moreira ME, Hernandez C, Stevens AD, Jones S, Sande M, Blumen JR, Hopkins E, Bakes K, Haukoos JS. Color-coded prefilled medication syringes decrease time to delivery and dosing error in simulated emergency department pediatric resuscitations. Annals of emergency medicine. 2015 Aug 31;66(2):97-106.
  6. Jung D, Carman M, Aga R, Burnett A. Disaster Preparedness in the Emergency Department Using In Situ Simulation. Advanced emergency nursing journal. 2016 Jan 1;38(1):56-68.
  7. Kessler DO, Walsh B, Whitfill T, Gangadharan S, Gawel M, Brown L, Auerbach M. Disparities in adherence to pediatric sepsis guidelines across a spectrum of emergency departments: a multicenter, cross-sectional observational in situ simulation study. The Journal of emergency medicine. 2016 Mar 31;50(3):403-15.
  8. Patterson MD, Geis GL, LeMaster T, Wears RL. Impact of multidisciplinary simulation-based training on patient safety in a paediatric emergency department. BMJ Qual Saf. 2012 Dec 1:bmjqs-2012.
  9. Miller D, Crandall C, Washington C, McLaughlin S. Improving teamwork and communication in trauma care through in situ simulations. Academic Emergency Medicine. 2012 May 1;19(5):608-12.
  10. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2012 Dec 1:bmjqs-2012.
  11. Petrosoniak A, Auerbach M, Wong AH, Hicks CM. In situ simulation in emergency medicine: moving beyond the simulation lab. Emergency Medicine Australasia. 2017 Feb 1;29(1):83-8.
  12. Siegel NA, Kobayashi L, Dunbar-Viveiros JA, Devine J, Al-Rasheed RS, Gardiner FG, Olsson K, Lai S, Jones MS, Dannecker M, Overly FL. In Situ Medical Simulation Investigation of Emergency Department Procedural Sedation With Randomized Trial of Experimental Bedside Clinical Process Guidance Intervention. Simulation in healthcare. 2015 Jun 1;10(3):146-53.
  13. Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, Oliver C, Ho HC, Speck C. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. Journal of surgical education. 2011 Dec 31;68(6):472-7.
  14. Zimmermann K, Holzinger IB, Ganassi L, Esslinger P, Pilgrim S, Allen M, Burmester M, Stocker M. Inter-professional in-situ simulated team and resuscitation training for patient safety: Description and impact of a programmatic approach. BMC medical education. 2015 Oct 29;15(1):189.
  15. Theilen U, Leonard P, Jones P, Ardill R, Weitz J, Agrawal D, Simpson D. Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. Resuscitation. 2013 Feb 28;84(2):218-22.
  16. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Simulation in Healthcare. 2011 Jun 1;6(3):125-33.
  17. Fan M, Petrosoniak A, Pinkney S, Hicks C, White K, Almeida AP, Campbell D, McGowan M, Gray A, Trbovich P. 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 Nov 1;6(11):e013683.
  18. Ullman E, Kennedy M, Di Delupis FD, Pisanelli P, Burbui AG, Cussen M, Galli L, Pini R, Gensini GF. The Tuscan Mobile Simulation Program: a description of a program for the delivery of in situ simulation training. Internal and emergency medicine. 2016 Sep 1;11(6):837-41.
  19. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+ 1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J. 2016 Jul 1;33(7):514-6.
  20. Petrosoniak A, Ryzynski A, Lebovic G, Woolfrey K. Cricothyroidotomy In Situ Simulation Curriculum (CRIC Study): Training Residents for Rare Procedures. Simulation in Healthcare. 2017 Apr 1;12(2):76-82.
  21. US Department of Health and Human Service. Quality improvement [Internet]. 2011 April [cited Dec 2017]. https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf
  22. Carne B, Kennedy M, Gray T. Crisis resource management in emergency medicine. Emergency Medicine Australasia. 2012 Feb 1;24(1):7-13.
  23. Kotter JP. Leading change. Harvard Business Press; 1996.