ORIGINAL ARTICLE Towards the Next Frontier for Simulation-Based Training Full-Hospital Simulation Across the Entire Patient Pathway Sonal Arora, PhD, ∗ Charles Cox, MBBS,† Simon Davies, MSc,‡ Eva Kassab, MSc, ∗ Peter Mahoney, PhD,§ Eshaa Sharma, MBBS, ∗ Ara Darzi, MD, FACS, ∗ Charles Vincent, PhD, ∗ and Nick Sevdalis, PhD ∗ Objective: To evaluate the efficacy of an entire hospital simulation in im- parting skills to expert healthcare providers, encompassing both retention and transfer to clinical practice. Background: Studies demonstrating the effectiveness of simulation do not concentrate upon expert multidisciplinary teams. Moreover, their focus is confined to a single clinical setting, thereby not considering the complex interactions across multiple hospital departments. Methods: A total of 288 participants (Attending surgeons, anesthesiologists, physicians, and nurses) completed this largest simulation study to date, set in the UK Defence Medical Services’ Hospital Simulator and the conflict zone in Afghanistan. The simulator termed “Hospital Exercise” (HOSPEX) is a fully immersive live-in simulation experience that covers the entire environment of a military hospital with all departments. Participants undertook a 3-day training program within HOSPEX before deployment to war zones. Primary outcome measures were assessed with IMPAcT (the Imperial Military Per- sonnel Assessment Tool). IMPAcT measures crisis management, trauma care, hospital environment, operational readiness, and transfer of skills to civilian practice. Reliability, skills learning, and retention in the conflict zone were assessed statistically. Results: Reliability in skills assessment was excellent (Cronbach α: nontech- nical skills = 0.87–0.94; environment/patient skills = 0.83–0.95). Pre/post- HOSPEX comparisons revealed significant improvements in decision making (M = 4.98, SD = 1.20 to M = 5.39, SD = 0.91; P = 0.03), situational aware- ness (M = 5.44, SD = 1.04 to M = 5.74, SD = 0.92; P = 0.01), trauma care (M = 5.53, SD = 1.23 to M = 5.85, SD = 1.09; P = 0.05), and knowledge of hospital environment (M = 5.19, SD = 1.17 to M = 5.42, SD = 0.97; P = 0.04). No skills decayed over time when assessed several months later in the real conflict zone. All skills transferred to civilian clinical practice. Conclusions: This is the first study to describe the value of a full-hospital simulation across the entire patient pathway. Such macrosimulations may be the way forward for integrating the complex training needs of expert clinicians and testing organizational “fitness for purpose” of entire hospitals. Keywords: nontechnical skills, simulation, surgery, teamwork, training (Ann Surg 2013;00:1–7) From the ∗ Department of Surgery and Cancer, St Marys Hospital, Imperial College London, London; †The Royal Wolverhampton NHS Trust, Wolverhampton, West Midlands; ‡University Hospital of North Staffordshire NHS Trust, Stoke- on-Trent, Staffordshire; and §Royal Centre for Defence Medicine, Birmingham, United Kingdom. Disclosure: Supported by the National Institute for Health Research (NIHR) and the Economic and Social Research Council (ESRC), UK. There was no specific funding for this research. The authors declare no conflicts of interest. The funders had no role in any aspect of the study. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: Sonal Arora, PhD, Department of Surgery and Cancer, St Marys Hos- pital, Imperial College London, London W2 1NY, United Kingdom. E-mail: Sonal.Arora06@imperial.ac.uk. Copyright C  2013 by Lippincott Williams & Wilkins ISSN: 0003-4932/13/00000-0001 DOI: 10.1097/SLA.0000000000000305 T he development and mastery of clinical skill using simulation has become acceptable adjuncts to supervised practice, pro- viding both learner-centered education and uncompromised patient care. 1,2 Reductions in working hours, advances in technology, and training curricula have contributed to this growing trend. Research has confirmed that technical skills acquired in the simulated set- ting transfer to improved operating room (OR) performance. 1 Such simulation-based training focusing upon an individual’s technical skill has become most prolific and can be termed “microsimulation” (Fig. 1). 3 It is typically aimed at surgical trainees. Both research and implementation are universally high with the “Fundamentals of Laparoscopic Surgery” program, for example, being extensively val- idated and mandatory in the United States (www.flsprogram.org). 4–6 Surgical educators are now advancing the field by concentrating on models of delivery necessary for optimal development of psychomo- tor skill—trialing distributed, 7 deliberate, 8 and mental practice 9 schedules. Alongside these exciting developments, there is a growing recognition of the fact that failures in communication and team- work are implicated in adverse events in surgery. 10–12 As a result, simulation-based training is now entering a more advanced phase, with a focus on team training in multidisciplinary environments. 13–16 This new era of simulation is focused upon the next level up and can be termed “mesosimulation” (Fig. 1). 3 At this level, senior trainees and consultant surgeons can practice their nontechnical skills, including how to best communicate and lead an OR team in a crisis. Emerging evidence suggests that such team simulations reduce the likelihood of errors and improve patient outcomes. Much of this work, how- ever, is confined to team training within a single setting in a hospital environment—typically the OR, the ward, or the intensive care unit (ICU). This narrow approach is necessary to make training feasible, but it artificially compartmentalizes care (and therefore training) into separate settings. It does not take into account the interactions with the wider hospital organization that impact on coordination of care (eg, OR team members have to ensure that a patient is fit for the OR preoperatively by chasing up necessary laboratory work and, in the case of a sick patient, they have to ensure that an ICU bed is available postoperatively). 17,18 For truly contextualized learning to occur, a simulation should mirror the clinical environment as closely as possible by providing an opportunity that would allow multiple clinicians to interact in real time across a fully integrated care pathway. 19 This third, most complex level of simulation-based training remains to be explored and implemented. It can be termed “macrosimulation”—a model of how an entire hospital functions (Fig. 1). 3 A macrosimulation con- sists of all facets of healthcare provided in a hospital to include organizational processes, patient pathways, diagnostic, imaging, and treatment modalities. It is particularly important in the light of re- cent research that has identified significant problems affecting patient safety across the full spectrum of the surgical care pathway. Hence, isolating training into distinct “silos” of skills (eg, teamwork within an OR or leadership in an ICU) is too limited in its approach. This narrow outlook fails to address the broader range of communication Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Annals of Surgery  Volume 00, Number 00, 2013 www.annalsofsurgery.com | 1