570 - Using Simulation and Debriefing to Prepare for High-risk Complex Multidisciplinary Procedures: Fetoscopic Endoluminal Tracheal Occlusion (FETO)

Publication Number: 3551.570

Louis Halamek, Stanford University, Palo Alto, CA, United States; Nicole K. Yamada, Stanford University School of Medicine, Palo Alto, CA, United States; Rodrigo B.. Galindo, Stanford University School of Medicine, Palo Alto, CA, United States; Susan R.. Hintz, Stanford University School of Medicine, Palo Alto, CA, United States

Background: Fetoscopic endoluminal tracheal occlusion (FETO) involves insertion of a balloon into the fetal trachea, reversibly blocking fluid efflux, stimulating lung growth and improving survival in congenital diaphragmatic hernia (CDH). Because of the complexity and risks of this intervention, FETO requires multiple disciplines, specialties and subspecialties to operate in a highly coordinated manner.

Objective: We sought to use simulation and debriefing to identify and remediate potential human and system weaknesses and resolve unanswered clinical process questions prior to launching our FETO program.

Design/Methods: Scenarios encompassing the range of potential maternal and fetal conditions arising during both routine and emergency situations were designed. Using patient simulators and task trainers, these scenarios were conducted conducted with interdisciplinary teams including neonatology, MFM, and ENT during four 3-hour sessions held in the operating rooms, taking three different forms:
• talk-throughs that allowed team members to ask questions requiring clarification
• walk-throughs that required team members to perform their roles during a slow-moving scenario, allowing time to answer questions
• run-throughs that proceeded in real time, followed by debriefings that identified weaknesses.
All were captured on video for later playback, transcription and analysis.

Results: 13 FETO scenarios were designed and conducted: scheduled balloon insertion (6), scheduled balloon removal (3), rapid maternal and/or fetal decompensation (4). The simulations, video analysis, briefings and debriefings resulted in:
1) a master contact list
2) communication protocols
3) 13 high-level decision trees to guide actions
4) action plans listing specific steps to be taken prior to a planned FETO procedure
5) equipment and supply checklists
6) diagrams for the setup of equipment/supplies and egress
7) general and specific situation awareness issues
8) questions requiring additional planning.

Conclusion(s): Simulation enabled creation of the framework for the FETO program, identification of latent safety threats, development of contingency plans to avoid time-pressured decision making, recognition of aspects of situation awareness that need to be understood by all team members, and issues requiring additional planning. This work illustrates the value of simulation and debriefing in preparing teams to undertake novel clinical programs and enhancing the potential to achieve flawless human and system performance and optimal patient outcome.

Figure 1 Decision Tree
High-level decision tree for Scenario 1C, one of the 13 plausible FETO scenarios

Figure 2. Setup
Diagram for the setup of equipment and supplies in surgical ORs 2, 3 and 6