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IMPRESS Expectations and Ground Rules 2022_23WORD

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Understanding the benefits of Simulation

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Abstract

One of the most important steps in curriculum development is the introduction of simulation- based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulation aides to replicate clinical scenarios. Although medical simulation is relatively new, simulation has been used for a long time in other high risk professions such as aviation. Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or 'fidelity'. Simulation- based learning is expensive. However, it is cost-effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider's competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.

Keywords: Clinical skills, medical education, medical simulation, simulators

INTRODUCTION

Medical education has undergone significant changes all over the world. One of the reasons for the changes is concern for the patient's safety. "To Err Is Human", a landmark report released by the Institute of Medicine (IOM) in 1999[ 1] estimated that medical errors cause injury to approximately 3% of hospital patients and results in a minimum of 44,000 and perhaps as many as 98,000 deaths per year in the United States. Another important finding came from the Harvard Medical Practice Study 1, in which the authors reviewed over 30,000 randomly selected hospital records at New York State in 1984 as part of an interdisciplinary study of medical injury and malpractice litigation. They found that injuries from adverse events occurred in 3.7% of hospital admissions, 27.6% of which were due to negligence and in which 13.6% led to death.[ 2] Medical errors also contribute to the cost of medical care throughout the world. The annual cost attributable to all adverse drug events and preventable adverse drug events for a 700-bed American teaching hospital was estimated by one study as $5.6 million and $2.8 million repectively.[ 3] Though it is expected that such medical errors occur in Saudi Arabia, there are no studies on their extent in Saudi hospitals.

Calls for a change in the instructional methods have resulted in innovative medical curricula. The new curricula stress the importance of proficiency in several clinical skills by medical graduates rather than mere acquisition of knowledge. As evidenced by their endorsement by many of the international bodies and medical schools,[ 4] it is universally accepted that clinical skills constitute an essential learning outcome. The acquisition of appropriate clinical skills is key to health education; however, students sometimes complete their educational programs armed with theoretical knowledge but lack many of the clinical skills vital for their work. A major challenge for medical undergraduates is the application of theoretical knowledge to the management of patients. Some medical schools in the Middle East have changed their curricula and adopted such educational strategies as problem-based learning. Also many medical schools have started to utilize clinical skills laboratories for training. However, simulation-based learning is not yet well established in this region. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method for undergraduate and postgraduate education.

MATERIALS AND METHODS

This is a narrative review of literature on a medical simulator and the use of simulation in medical education. A literature search of MEDLINE/PubMed database for English-language publications and reference lists from relevant articles published between 1990 and August 2009 was conducted. The main search terms were medical simulation, medical simulator, medical education, and clinical skills. All articles thought to be relevant to the title and/or abstracts were retrieved. These articles were reviewed if they were considered relevant to the search.

CLINICAL COMPETENCE

Medical training programs should ensure that students have the necessary learning opportunities and assessed by the appropriate methods. Clinical skills competencies including communication skills, history-taking, professional attitudes, awareness of ethical basis of healthcare, physical examination, procedural skills, clinical laboratory skills, diagnostic skills, therapeutic skills, resuscitation skills, critical thinking, clinical reasoning, problem solving, team-work, organization skills, management skills, and information technology skills should be part of the core undergraduate curriculum.[ 5] Traditionally, the acquisition and ongoing improvement of high level psychomotor skills required by future physician take place in an apprentice-style model of 'See One, Do One, Teach One.' This apprentice-style of learning is no longer considered acceptable because of the increasing concern for the quality of patient care and safety and change in health care systems. The pressure of managed care has shaped the forms and frequency of hospitalization and led to a higher percentage of acutely ill patients and shorter inpatient stays. This has resulted in fewer opportunities for the medical learner to access a wide variety of diseases and physical findings. Relying on exposure to real hospital patients during training years may result in an ad-hoc method of learning clinical skills, as this depends on the availability of cases, and consequently to less than optimal development and performance of clinical skills. There are many reports that indicate concerns for the level of skills medical graduates even in western countries possess.[ 6, 7]

The acquisition of expertise in clinical medicine requires the learner's engagement in deliberate practice of desired learning outcomes. According to Issenberg et al (2002)[ 8] "Deliberate practice involves (a) repetitive performance of intended cognitive or psychomotor skills in focused domain, coupled with (b) rigorous skills assessment, that provides learners (c) specific, informative feedback, that results in increasingly (d) better skills performance, in a controlled setting." Concerns about patient safety and fewer available patients for learning, and many other factors have led to the introduction of simulation and the development of simulation centers and clinical skills laboratories in medical education.[ 9, 10]

SIMULATION

Aviation and aerospace industries have been using simulation as a teaching tool for many years. Simulators are now widely used in education and training in a variety of high risk professions and disciplines, including the military, commercial airlines, nuclear power plants, business and medicine.[ 11] Recently, the inclusion of clinical skills training into the curricula of medical students has seen significant growth. There are many examples of curricular reform that include clinical skills training, the use of simulators, and the creation of clinical skills centres.[ 12] Simulation has been defined as a situation in which a particular set of conditions is created artificially in order to study or experience something that is possible in real life; or a generic term that refers to the artificial representation of a real world process to achieve educational goals via experimental learning.[ 13] A simulator is defined as a device that enables the operator to reproduce or represent under test conditions phenomena likely to occur in actual performance. On the other hand, simulation based medical education can be defined as any educational activity that utilizes simulative aides to replicate clinical scenarios. Simulation tools serve as an alternative to the real patient. Trainers can make mistakes and learn from them without the fear of distressing the patient.[ 14] Experiential learning, which is a part of the definition of simulation, is an active process during which the learner constructs knowledge by linking new information and new experience with previous knowledge and understanding. Experiential learning or learning from experience during simulation based training sometimes involves the use of clinical scenarios as the bases of learning.[ 15, 16] The practice of scenarios can be done individually, but it is mostly carried out by a team from the same or different specialties or professions in a simulated environment made to resemble the intended environment as closely as possible in order to immerse students in an experience closest to real life.[ 17, 18] The practice of a scenario can be videotaped for immediate feedback to participants during the debriefing sessions.

Debriefing after a scenario is an important component of full-scale simulation. Video recording of the scenario is also used to initiate discussion and to make sure that all learning objectives were covered. Debriefing can focus both around the cognitive process involved in the recognition of the problem and the implementation of the management guidelines and the technical level at which the ability of the learner to apply rules and appropriate responses in a stressful situation is evaluated.[ 19]

During the full scale scenario-based training, the learner can acquire such important skills as interpersonal communication, teamwork, leadership, decision-making, the ability to prioritize tasks under pressure, and stress management.[ 13] However, training through simulation should be viewed as an adjuvant and not a replacement for learning with real patients. Simulation is not intended to replace the need for learning in the clinical environment, so it is important to integrate simulation training with the clinical practice during curriculum development.

SIMULATOR

Simulators are classified into different categories.[ 20, 21] An example of the classification of simulators is shown in . Simulators can be classified according to their resemblance to reality into low-fidelity, medium- fidelity and high-fidelity simulators.[ 20] Low-fidelity simulators are often static and lack the realism or situational context. They are usually used to teach novices the basics of technical skills. Example of a low-fidelity simulator is the intravenous insertion arm [] and Resusci-Anne []. Moderate fidelity simulators give more resemblance of reality with such features as pulse, heart sounds, and breathing sounds but without the ability to talk and they lack chest or eye movement. They can be used for both the introduction and deeper understanding of specific, increasingly complex competencies. An example of a moderate fidelity simulator is the "Harvey" cardiology simulator []. High fidelity simulators combine part or whole body manikins to carry the intervention with computers that drive the manikins to produce physical signs and feed physiological signs to monitors. They are usually designed to resemble the reality. They can talk, breathe, blink, and respond either automatically or manually to physical and pharmacological interventions. Good examples of high-fidelity simulator is the METI Human Patient Simulator (HPS) which is model driven [] and the "Noelle" obstetric simulator which is instructor driven. In general, the higher the fidelity, the more expensive it is.

Table 1

Virtual reality can also be incorporated into the simulators (mostly part-task simulators) to enhance learning. Virtual reality is best described as a concept of advanced human-computer interaction. Virtual reality varies greatly according to its level of sophistication in its level of realism and of the user's interaction with the virtual environment.[ 22] A common form of virtual reality involves the use of haptic (touch) feedback to produce a feeling of resistance when using instruments in a simulated environment. This technology is frequently used in endoscopic and laparoscopic dexterity training. High-fidelity and virtual reality simulations can bridge the gap between theory and practice by immersing the learner in a realistic, dynamic, complex setting.

Nonetheless, simulation can only imitate but not replicate reality. The recreation of "reality" or "fidelity" is important for the success of simulation and for the participant. Since some simulators can be used to encourage independent or self-directed learning, they should be integrated into the overall curriculum. However, to make learning effective, important conditions are necessary during simulation practice. The intended outcomes should be predefined and the training carried out in a controlled environment. Effective learning requires repetitive practice and feedback during the learning experience. Issenberg et al[ 22] performed an excellent systematic review and identified ten features of high-fidelity medical simulation that can lead to effective learning. Those ten features are listed in .

Table 2

SIMULATION BASED TRAINING

Simulation can be used to resemble existing curricular material. The simulated scenarios are realistic enough to engage the students emotionally, thus providing a unique learning experience, where the high fidelity simulator "patient" actually talks, breathes, blinks, and moves like a real patient. Simulation can be adapted to accommodate the need of various medical specialties such as anesthesia, emergency medicine and trauma, intensive care medicine, obstetrics, pediatrics, and radiology as well as for the use of other professionals such as nurses, paramedics, and respiratory therapists.[ 13, 24, 25]

Simulation laboratories are quite costly. A single high-fidelity simulator with its monitoring system and other necessary equipment may cost up to $200 000. In addition, synthetic body fluids, replacement skins, bandages, syringes and other supplies are necessary to simulate the experience of treating real patients in a real hospital. The ability to practise without risk must be weighed against the cost of this new technology. Simulation has many advantages, for it results in highly trained medical graduates who are less likely to make life-threatening or costly medical errors.[ 21, 23] Some of the advantages of simulation are listed in . Employing medical simulation techniques can help move medical training from the old "See One, Do One, Teach One" method into a "See One, Practice Many, Do One" model of success.[ 26] Simulation-based teaching has proved to reduce risks to both patients and learners.[ 27, 28] It has also proved to be effective in both undergraduate and post graduate education as well as faculty development.[ 29, 30] Simulation can be used in the primary health care setting to improve confidence in performing life-saving skills,[ 31] clinical skills,[ 32, 33] communication skills,[ 34] and the quality of care for patients with chronic diseases such as diabetes mellitus and bronchial asthma.[ 35, 36] Such simulators as part task trainers, computer-based systems, virtual reality and the haptic system, simulated patients, simulated environment, and integrated simulators have been also used effectively to assess and evaluate clinical skills.[ 10, 37, 38] The major challenge to medical simulation is the fact that evidence to date is weak in methodology. Most of the published work is descriptive and limited in generalisability. The assumption that such learning is directly transferable to the clinical context is often untested.[ 39] Only a few studies have shown a direct positive impact in the clinical outcome from the use of simulation for medical training.[ 40]

Table 3

In conclusion, the promise of simulation-based medical training offers useful opportunities to reduce risks to patients and learners, improve learners' competence and confidence, increase patient safety, and reduce health care costs in the long run. However, robust research is needed to see if simulation training does actually improve patient outcomes.

Footnotes

Source of Support: Nil

Conflict of Interest: Nil

REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington DC: National Academy Press; 1999. [ Google Scholar]

4. Smith SR, Dollas R. AMEE Guide No 14: Outcome-based education: Part 2- Planning, implementing, and evaluation of competency-based curriculum. [ Google Scholar]

5. Ledingham McA, Harden RM. Twelve tips for setting up a clinical skills training facility. [ Google Scholar]

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Simulation-based medical teaching and learning

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One of the most important steps in curriculum development is the introduction of simulation- based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals ...

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Human Factors/Non-Technical Skills Presentation 

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Human Factors/Non-Technical Skills Presentation 

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Trent Simulation & Clinical Skills Centre

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Trent Simulation & Clinical Skills Centre

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If the BMJ Best Practice video links provided won't play - please sign into the BMJ Best Practice website or app and you will find all the skills animations listed in the 'videos' tab. Alternatively access through the search function

Access is free when registered with an nhs.net email account

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Diagnostic lumbar puncture in adults: animated demonstration

Equipment needed

Prepare all the equipment on a sterile trolley surface with an assistant's help.

Sterile gloves and eye protection; it is now common practice for clinicians to wear face masks while performing a lumbar puncture

Fenestrated sterile drape

Chlorhexidine in alcohol (usually spray or swabstick)

10 mL syringe

25-gauge needle (orange)

23-gauge needle (blue)

1% lidocaine local anaesthetic

Spinal needle (ideally an atraumatic spinal needle)

Introducer needle (may be used if using an atraumatic spinal needle)

Manometer tube with three-way tap

Three clear specimen tubes (or four if you suspect subarachnoid haemorrhage)

One fluoride oxalate blood bottle for glucose (grey-topped)

Occlusive dressing.

Contraindications

Raised intracranial pressure: patients may present with:

Performing a lumbar puncture (LP) in a patient with raised intracranial pressure may cause fatal herniation of the brain (coning). Lumbar puncture causes a low pressure shunt to form at the site of the LP where cerebrospinal fluid (CSF) can escape. As the CSF pressure drops in the spinal column, CSF and brain tissue may shift towards the low pressure outlet (the site of the LP) leading to either transtentorial or uncal herniation, and subsequently acute neurological deterioration. Coning can lead to coma and death. Careful selection of patients suitable for lumbar puncture, and the use of computed tomography (CT) scanning of the brain, should minimise the risk of performing an LP. At a minimum, all patients undergoing LP should have fundoscopy to inspect for papilloedema performed prior to the procedure.

Coagulopathy: there is a severe risk of bleeding after lumbar puncture if an uncorrected coagulopathy is present. This includes patients on heparin, warfarin, or other oral anticoagulants, or with clotting defects such as disseminated intravascular coagulation, thrombocytopenia, or haemophilia. When the clotting abnormalities are corrected, a lumbar puncture is no longer contraindicated.

Suspected cauda equina syndrome or central cord compression: cauda equina syndrome can be caused by central disc prolapse, tumour, abscess/tuberculosis, haematoma, or trauma. Symptoms include urinary incontinence or retention (may be painless), faecal incontinence, bilateral leg weakness, and pain. Signs may include bilateral reduced power (lower motor neuron) and sensation, reduced perianal (saddle) sensation, reduced anal tone, and bilateral absent ankle reflexes. It is diagnosed by urgent MRI scan of the spine. Patients with cauda equina syndrome need immediate referral to the orthopaedic team or neurosurgeons for surgery. It is not diagnosed by lumbar puncture.

Allergy to local anaesthetic

Refusal by the patient (if they have the capacity to do so)

Cellulitis/abscess overlying the lumbar spine (risk of introducing infection into the CSF).

Indications

Indications for diagnostic lumbar puncture include clinical suspicion of:

Meningitis: bacterial, viral, fungal, or tuberculous infections of the central nervous system (CNS)

Encephalitis

Subarachnoid haemorrhage

Neoplastic disease

Demyelinating diseases (e.g., multiple sclerosis)

Peripheral neuropathies (e.g., acute inflammatory demyelinating polyradiculoneuropathy, the most commonly encountered variant of Guillain-Barré syndrome).

Complications

Bleeding: Minor bleeding is common, but the formation of an epidural or spinal haematoma may result in neurological deficits. If this happens, urgently seek a neurosurgical opinion.

Headache: Up to around 35% of patients may experience a headache following an LP.[101]Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. 2006 Oct 24;67(8):1492-4. http://www.ncbi.nlm.nih.gov/pubmed/17060584?tool=bestpractice.com It typically occurs within 48 to 72 hours of the procedure, and may take up to 2 weeks to resolve. Patients describe a constant, dull ache bilaterally that is more frontal than occipital. The most characteristic symptom is positional (orthostatic) exacerbation (i.e., the patient has headache pain when upright but generally no pain when supine). The cause is thought to be continued leakage of CSF from the puncture site, and intracranial hypotension. There is good evidence that using atraumatic needles (also known as pencil-point needles) reduces the incidence of post-dural puncture headaches.[102]Arendt K, Demaerschalk BM, Wingerchuk DM, Camann W. Atraumatic lumbar puncture needles: after all these years, are we still missing the point? Neurologist. 2009 Jan;15(1):17-20. http://www.ncbi.nlm.nih.gov/pubmed/19131853?tool=bestpractice.com[103]Nath S, Koziarz A, Badhiwala JH, et al. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. 2018 Mar 24;391(10126):1197-204. http://www.ncbi.nlm.nih.gov/pubmed/29223694?tool=bestpractice.com[104]Rochwerg B, Almenawer SA, Siemieniuk RAC, et al. Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline. BMJ. 2018 May 22;361:k1920. https://www.bmj.com/content/361/bmj.k1920.long http://www.ncbi.nlm.nih.gov/pubmed/29789372?tool=bestpractice.com If using a conventional needle, you can help prevent headaches occurring by using the smallest needle that is practical, and by keeping the bevel aligned parallel with the dural fibres. If headache occurs following an LP, manage the patient with simple analgesia, rehydration, and antiemetics if there is associated nausea.[105] Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006 Nov;82(973):713-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660496/ http://www.ncbi.nlm.nih.gov/pubmed/17099089?tool=bestpractice.com For severe or prolonged headaches, ask an anaesthetist about a blood patch, where a small amount of autologous venous blood is injected into the adjacent epidural space to 'clog up the hole'. An infusion of intravenous caffeine is an option for the treatment of headaches following an LP, but the evidence for this is sparse.

Infection: Adherence to a strict aseptic technique will minimise this risk.

Nerve root pain or paraesthesia: Irritation of nerves or nerve roots by the spinal needle can cause dysaesthesias of the lower extremity. Withdrawing the needle without replacement of the stylet can cause aspiration of a nerve or arachnoid tissue into the epidural space. Replace the stylet before moving the needle to prevent this complication.[105] Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006 Nov;82(973):713-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660496/ http://www.ncbi.nlm.nih.gov/pubmed/17099089?tool=bestpractice.com

Failure to collect CSF (a dry tap): Dry taps generally result from misplacement of the spinal needle, most commonly lateral displacement. This can be corrected by complete withdrawal of the needle, re-evaluation of the patient's anatomy, and reinsertion in the correct place and at the correct angle. In obese patients the regular spinal needle might be too short, so a longer one may need to be used.

Coning: This serious complication can lead to coma and death. Careful selection of patients suitable for lumbar puncture, and use of CT scanning of the brain, should minimise the risk of performing an LP.

Back pain: A potential complication of LP.

Aftercare

Ensure all sharps are disposed of carefully.

Neurological observations should be performed frequently. A Cochrane systematic review found no benefit in advising routine bed rest for preventing the onset of post-dural puncture headache compared with immediate mobilisation.[106] Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, et al. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2016 Mar 7;(3):CD009199. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009199.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/26950232?tool=bestpractice.com

Send specimens to the lab with request cards completed and bottles labelled accurately.

Send sample two, the fluoride tube, and the blood sample for biochemistry (protein, glucose, pH). Send samples one and three to microbiology for microscopy, culture, and sensitivity (consider requesting viral culture/polymerase chain reaction). If you suspect a subarachnoid haemorrhage, send the fourth sample in an envelope (to exclude light) to biochemistry for xanthochromia.

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Equipment needed Prepare all the equipment on a sterile trolley surface with an assistant's help.

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Needle Decompression of Tension Pneumothorax

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Needle Decompression of Tension Pneumothorax

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Intercostal Drain Insertion - Seldinger technique

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Intercostal Drain Insertion - Seldinger technique

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Radial artery puncture animated demonstration

Equipment needed

The equipment for radial artery puncture includes:

Alcohol wipes

Sterile gloves, protective glasses, and apron

Cotton wool or gauze

Pre-heparinised 3mL arterial blood gas syringe, a rubber block, and cap

23 gauge needle.

Contraindications

Absolute contraindications include:

Absence of a palpable pulse in an otherwise conscious patient

Prosthetic arterial bypass graft or stent at intended site of puncture

Arteriovenous fistula

Aneurysmal artery

Negative Allen's test indicating insufficient ulnar artery supply to the hand

Cellulitis or other infections in the tissues overlying the radial artery (particularly as other sites are likely to be available).

Relative contraindications include:

Indications

Arterial blood gas sampling is used together with clinical assessment, venous blood samples, imaging, and physiological tests to help with diagnosis, treatment, and monitoring the response to treatment in a variety of clinical settings. When radial puncture is not possible, the femoral artery provides an alternative - for example, in the peri-arrest situation, or when the patient has a contraindication to radial puncture.

Several parameters of arterial blood are measured from the sample, including:

Complications

Complications include:

Bleeding, bruising, and haematoma formation

Local infection or cellulitis

Nerve injury

Formation of a false aneurysm

Vasospasm, thrombosis, or embolus, causing transient or significant ischaemia to the distal extremity (this is rare)

Needle stick injury if insufficient care is taken when pushing the needle into the rubber block before disposal.

Aftercare

Maintain pressure over the arterial puncture site for several minutes. This action can be delegated to an assistant, while the person who performed the procedure carefully disposes of the sharps, labels the specimen, and organises for it to be analysed.

Check the patient several minutes after the procedure to make sure that the perfusion of the extremity is adequate and the arterial puncture site is not haemorrhaging or forming a haematoma.

Send the sample for analysis immediately, labelling and documenting the inspired oxygen concentration clearly.

Normal values for arterial blood vary slightly in each laboratory and machine, and these values should be cross-referenced when interpreting the results of arterial blood gas analysis. Some blood gas analysers also need the patient's temperature.

An unexpected or very abnormal result may indicate serious pathology or indicate that a venous sample was taken.

# data[].attributes.attachment_link.description
Equipment needed The equipment for radial artery puncture includes: Alcohol wipes Sterile gloves, protective glasses, and apron Cotton wool or gauze Pre-heparinised 3mL arterial blood gas syringe, a rubber block, and cap 23 gauge needle.

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Tachycardia & Bradycardia management presentation LTHT

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Tachycardia & Bradycardia management presentation LTHT

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Ascitic Tap & Paracentesis presentation LTHT

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Ascitic Tap & Paracentesis presentation LTHT

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Femoral venous access (Seldinger technique) 

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Femoral venous access (Seldinger technique) 

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Updated algorithm for Pleural procedures - July 2023

Full published guidance available on Pleural Procedures | British Thoracic Society | Better lung health for all

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BTS Guideline for Pleural Disease Appendix 1_ Clinical Pathways_decision trees

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Resus council

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Adult tachyarrhythmia algorithm V3 March 2026

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Resus council

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For guidelines access on the go

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Healthcare professionals can access guidelines on the go with Resuscitation Council UK's iResus app.

iResus provides quick and easy offline access to all the latest algorithms from Guidelines 2015 so they can be used in an emergency - even if you don't have the internet.
Download now:

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Healthcare professionals can access guidelines on the go with Resuscitation Council UK's iResus app. iResus provides quick and easy offline access to all the latest algorithms from Guidelines 2015 so they can be used in an emergency - even if you don't have the internet. Download now:

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BMJ Best Practice Procedural videos login 

# data[].attributes.subject
BMJ Best Practice Procedural videos login 

# data[].attributes.attachment_link.description
Watch videos on common clinical procedures. Videos include a list of equipment, complications, indications, contraindications and aftercare.

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The National Safety Standards for Invasive Procedures (NatSSIPs) website

(If link doesn't work this is readily available through any search engine)

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The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Our understanding of how to deliver safe care in in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.

NatSSIPs2 consists of two inter-related sets of standards:

The organisational standards are clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care.

The sequential standards are the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure[1].

The NatSSIPs2 have evolved to have less emphasis on tick boxes or rare 'Never Events' and now include cautions, priorities and a clear concept of proportionate checks based on risk. We recognise that 'teams' change or may be newly formed on the day of a procedure, and therefore require clear processes. NatSSIPs2 should form the basis of improvement work, inspections and curricula.
Key principles in NatSSIPs2 include:

The concept that NatSSIPs2 will help achieve of the triple goals of improved patient safety, better team-working and enhanced efficiency.

The categorisation of invasive procedures into major or minor procedures, each requiring different checks which are proportionate to the risk of harm.

The benefit of 'Standardisation, Harmonisation, and Education' across invasive specialty processes.

The need to consider human factors with systems thinking, culture, psychological safety and team-work to underpin NatSSIPs2 implementation.

An update of the WHO Five steps to safer surgery of Team Brief, Sign In, Time Out, Sign Out and Handover/Debrief to include three more steps to make the Sequential Standards (Steps): Consent and Procedural verification; Safe use of implants; and Reconciliation of items (to prevent retained foreign objects). 'The NatSSIPs Eight' should be in place for every relevant patient.

That checks performed by an engaged team enable communication and save misunderstandings, reduce risk, provide clarity and set expectations

The central role of the patient as a participant in safety checks.

The need for a learning safety system supported by insight, involvement and improvement.

A structure of People, Processes and Performance within the organisational standards

The requirement for adequately resourced organisational leadership and support for safety.

The NatSSIPs2 have been written by practising clinicians, from across the four UK nations, across disciplines, professions and organisations, with patient and organisational input and published by the Centre for Perioperative Care. They incorporate safety science and learning from all UK nations' patient safety strategies and major reports and investigations.

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The National Safety Standards for Invasive Procedures (NatSSIPs)

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CPOC has been tasked by NHSE/I to review The National Safety Standards for Invasive Procedures standards