Lessons Learned – Implementation of a Simulation Equipment Loan Guideline at a Tertiary-Care Academic Health Sciences Center
Authors
Holly D. Sarvas, MEd1, Kyle Mispel-Beyer, MSc1, Alexander M. Wood, BScN1
1Health Sciences North, Simulation Lab, Sudbury, Ontario
Conflict of Interest Statement
The authors Holly D. Sarvas, Kyle Mispel-Beyer, and Alexander M. Wood have no conflicts of interest to declare.
Corresponding Author
Holly D. Sarvas, MEd, Health Sciences North, Simulation Lab, Sudbury, Ontario
(Email: simeducators@hsnsudbury.ca)
Abstract
A simulation laboratory (lab) is limited in the amount of hands-on education programs it can host at any given time because of both human resources and physical space. This means task trainers, manikins, or equipment go unused, despite educators being available to implement training that day. To combat an overburdened simulation lab’s schedule, our team has developed an equipment loan program for educators to take advantage of available simulation equipment. Since this new program’s inception in June of 2022, it has led to the education of hundreds of learners and staff on over 15 different skills, with minimal impact to equipment condition.
Introduction
Simulation-based education is a necessary modality for learners and healthcare professionals to achieve and maintain competence in skills, through deliberate practice and mastery learning (McGaghie et al., 2014; McGaghie et al., 2011). While many institutions support simulation, the equipment to simulate skills can often be expensive or complicated to reproduce (Qayumi et al., 2014), meaning these institutions may only acquire a few pieces of equipment to support 100s to 1000s of learners and staff. To ensure the integrity and longevity of equipment, simulation labs and their technicians are often tasked with the maintenance, well-being and safeguarding of equipment (Lowther & Armstrong, 2023). By being protective with the usage of simulation equipment, institutions can lessen costs and still promote hands-on learning. However, simulation staff cannot always oversee learner groups, and the human resources or the physical space available to them often limit them (Qayumi et al., 2014). This usually means that certain manikins, task trainers, or associated equipment goes unused. Unused equipment may still have been beneficial to instructors, preceptors, or other educators who would apply them to their learning sessions.
Simulation labs and their associated institutions need to balance the risk of equipment being misused or lost against the benefit of providing ongoing deliberate practice of skills in their organization. Legitimate risk exists with certain equipment being misused for patient purposes, or becoming damaged (Raemer et al., 2018). Legitimate benefits to staff, learners, and patients also exists from task trainers and simulation equipment being available just-in-time and just-in-place for hands-on learning (Donoghue et al., 2021; Lengetti et al., 2011). This article will describe the success of a simulation lab’s design and implementation of an equipment loan program and their year in progress. Included in the discussion are key considerations for safety of equipment, coordination, and maintaining rapport with educators.
Discussion
An Overview of our Simulation Lab
When implementing simulation equipment loan guidelines, the simulation lab team must consider the user base, and feasibility of the process within their individual center. The guideline described herein was implemented at a simulation lab that services a 415+-bed tertiary-care academic health sciences center, a medical school, and a regional certifications program. Our simulation lab is situated directly on the main campus of the hospital, with direct access to the inpatient units and emergency department. One floor below us is a dedicated learner center, with two classrooms and one meeting space specifically for medical, nursing, and allied health learners. Our conveniently located simulation lab was ideal for implementing an equipment loan program. We also had long-standing relationships with our Nurse Clinician forum, Clinical Placement Advisors, and medical school Program Coordinators to promote this process. At our facility, nurse clinicians act in the role of educators and coordinators of frontline nursing and allied health staff for certifications, skills, continuing education, and policy management.
Design of Guideline
Our equipment loan guideline was co-developed with the Simulation Manager, the Simulation Educators, a Simulation Technician, and the Simulation Lab Administrative Assistant. The guideline is three pages in length, with three appendices. The appendices reference a) the signing out log kept by our administrative assistant, b) the attestation form witnessed upon sign-out of the equipment, and c) the attestation form upon sign-in of the equipment. The wording of the guideline was specifically constructed to ensure the following 5 criteria:
1. Equipment is not required at the Simulation Lab.
The first concern with loaning equipment is that the needs of external educators (i.e. borrowers) could conflict with the simulation lab’s programs. This would result in sub-par simulations at the lab or the inability to meet key learning objectives because of the lack of coordination of supplies/equipment. To combat this concern, a strict requesting and sign-out process was implemented to avoid conflicts with simulation supplies. All requests are required to go through the internal simulation lab email stating: the specific equipment and quantity of equipment request, the exact timeframe for the loan, the exact location where the equipment is going, and the contact information of the borrower (see Appendix A). The borrower would then attest to this information again upon sign-out, with an obligatory signature. This process allowed our administrative assistant to cross-reference the loan request with scheduled programming (in consultation with a Simulation Technician, as required) to ensure no conflicts, while also giving our simulation lab the ability to retrieve the equipment if a last-minute need arose.
2. Equipment is used and stored in a safe location.
The second concern with loaning equipment is the potential for it to be lost while on loan. To combat this concern, wording in the guideline restricts equipment to be loaned out for only small periods of time (2 hours to 48 hours), unless managerial approval is sought, to minimize the risk of equipment jumping from location to location. Additionally, the borrower must indicate the exact room in which the equipment will be stored while loaned out. The guideline also states that ‘The borrower will ensure the equipment is in a location away from patients and visitors, or that it is monitored when in a space accessible to the general public’. Should the equipment be stolen or lost while loaned out, liability is placed on the borrower, which encourages them to be mindful with the equipment.
3. Equipment is used appropriately.
The third concern is that the simulation equipment is used inappropriately, resulting in damage to the equipment, or allowing it to be misused for patient care purposes. As such, our department made it mandatory that educators are the only individuals who can sign out the equipment, not learners. Additionally, educators must be orientated to the equipment (i.e. task trainers, manikins) prior to sign-out to ensure appropriate usage. Borrowers must attest that they will provide sufficient instruction on the use of loaned equipment to their learner group prior to starting education. The borrower must also attest they are teaching the skill to best practice guidelines or organizational policy. Finally, the borrower will attest that under no circumstances will the equipment be used for patient care purposes (see Appendix B). A not-for-human use sticker (Foundation for Healthcare Simulation Safety, n.d.), is affixed to all equipment that could be inadvertently used for patient care purposes (i.e. IV pumps). As an additional safety consideration, our equipment is routinely serviced by our Biomedical Department in case a user error does occur, or the sticker falls off.
Our simulation center also determined that only certain equipment could be loaned to mitigate risk for misuse. This means only low-fidelity manikins and task trainers would be considered loanable. Our high-fidelity manikins, VR/AR task trainers, or otherwise complex equipment would not be loaned out to minimize risk for misuse, as any damage to this equipment or subsequent downtime would be costly and/or impact upcoming simulations. We also strongly encouraged loaning out our do-it-yourself task trainer models over commercial products that were purchased by our simulation lab (i.e. homemade wound care trainers, injection pads, etc.) if it did not compromise learning objectives. This decision was made because if the models were misused or lost, it was easier to reconstruct or replace than commercial task trainers on a tight budget.
4. Equipment does not become damaged.
The fourth concern is that the simulation equipment becomes damaged while outside the control of our department and simulation staff. To combat this, our department required the borrower to undergo orientation to the equipment alongside a Simulation Technician prior to sign-out. As noted above, the guideline clearly stated the equipment must be in a safe place at all times while away from the simulation lab. By attesting to our guideline, the borrower agrees that should the equipment become broken or otherwise unusable, they are to immediately contact the simulation lab. The equipment will either be immediately returned, or a Simulation Technician will be deployed to the area to assess the state of the equipment. With their attestation, the borrower takes on the liability of the equipment should damage be caused due to negligent use. Finally, on return of the equipment to the simulation lab, the borrower is agreeing to an inspection by a Simulation Technician to ensure the equipment is in working order.
5. Maintain strong rapport with educators/borrowers.
The final concern is that any misuse or abuse of the equipment loan process could cause tension or reduced rapport with borrowers upon further engagement with the simulation team for routine simulation programs. Balancing the potential cost of damaged or lost equipment alongside positive relationships with educators needs to be weighed for each individual simulation center. To minimize the risk of degradation of relationships with educators, our simulation lab added wording that explicitly stated that the equipment loan process is a privilege that could be revoked if used improperly. This statement, alongside the liability statement, set clear expectations and boundaries for our educators to use the program responsibly. Mandatory orientation with equipment also resulted in a lessened risk for misuse of equipment. Finally, the strict adherence to the process by our administrative assistant and simulation team meant borrowers who might have abused the process were generally deterred through email communications or first use.
Changes to Internal Processes Due to Guideline
Only two minor changes needed to occur to our internal processes to implement this program. First, a binder was created with the sign-out log and attestation forms, which was managed by our administrative assistant. The log is uploaded on a bi-monthly basis to an Excel sheet stored on our internal simulation lab drive to keep metrics on the process. The final change was an Outlook folder that was added to our internal simulation lab inbox, along with calendar reminders, to track requests and correspondences between educators.
Revisions Made to Guideline Processes
Amount of equipment borrowed.
Initially, our simulation lab had not stated in our guideline a limit on the total pieces of equipment that could be borrowed at any given time. When prompted by a particularly sizeable ask for many different pieces of equipment, we limited the number of pieces each department/educator could loan out at a time to five; ultimately to minimize risk of misuse, misplacement, or conflict between our internal scheduled programs. This change has seen no concerns since integration.
Maximum length of time to borrow equipment.
As noted above, we started with a maximum of a 48-hour window to borrow equipment, unless simulation lab managerial approval was sought. This came into conflict with weekends or statutory holidays where educators may want to borrow on the Friday evening, over the weekend, or before operational hours on the Tuesday post-holiday. To combat this concern, we extended the window to a maximum of 72-hours. This change has not seen any concerns from our simulation lab or users.
Mitigating unsupervised equipment during preceptor borrowing.
As the academic year starts up, most academic institutions are interested in having their preceptors make use of our equipment loan program to supplement their clinical placement while they are on-site. The concern arose that not all preceptors have access to protected space to lock away equipment between their placement days, placing equipment at risk of being stolen or misused when not monitored by the preceptor. To combat this concern, we distinguished preceptor-educators from hospital-based-educators. Wording was placed in our guideline that states that preceptors can only borrow during times of placement unless a departmental supervisor has consented to locking away the equipment between placement days. We have yet to see the effects of this change.
A Year in Review - Implementation of a Loaning of Equipment Guideline
Since the inception of the equipment loan program described herein (June 2022 until September 2023), 60 pieces of equipment have been borrowed via 45 separate loaning requests by educators in the organization. The most common pieces of equipment borrowed include adult CPR manikins, IV insertion arms, airway insertion task trainers, and IV pumps. Equipment was loaned to inpatient and outpatient departments, operating rooms, nursing student groups, and resident learner settings. The median time for loaning was less than 1 day with 7 instances occurring for greater than 3 days. In only 3 instances were there issues that occurred with the loaned equipment. Two minor issues occurred with urinary catheter task trainers leaking, which was rectified with further educator orientation. One larger issue arose when the neck of a nasogastric task trainer broke from a fall while on loan. This issue was rectified with Simulation Technician repairs, and it was determined that a charge/fee was not required of the borrower. Educators continue to request access to our equipment loan process, and our guideline is now integrated into our clinical preceptor onboarding orientation to further promote its usage.
Conclusion
As demonstrated herein, an equipment loan program can be instituted at a busy academic teaching hospital simulation lab with minimal disruption to concurrent programming, minimal risk to equipment and without compromising patient care. If a simulation lab wishes to implement a similar program within their center, they must weigh the benefits of supporting deliberate practice and mastery learning outside their walls alongside the risk of equipment damage, misuse, or loss. A strong rapport with educators at the institution will promote adherence to a loaning of equipment guideline, whilst proximity to patient centers and/or learning centers will promote feasibility of returning equipment in a timely manner. This process could potentially aid institutions that are facing high staff turnover, seeing larger learner cohorts, or looking to increase skills within their organization without the need for further funding, human resources, or physical space.
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