MSF field simulation - incorporating simulation into the plan-do-study-act cycle for an integrative improvement of the OPD triage system, Pulka, Nigeria

BACKGROUND AND AIMS
Simulation in healthcare education is well known, but the role of simulation in quality improvement (QI) processes is less recognised. MSF Field Simulation developed a pilot using simulation to understand and address the problem of late detection of critically ill paediatric and adult patients presenting to a hospital-level OPD, in Pulka, Nigeria, after staff raised concerns that ‘red’ cases were frequently missed at triage. We aimed to show the value of incorporating simulation into the Plan-Do-Study-Act (PDSA) cycle in the analysis and redesign of the existing triage system.

METHODS
Simulation was incorporated into each stage of the PDSA-cycle. PLAN: a tabletop simulation exercise was used to identify areas for improvement and potential solutions, completing the cause-and-effect diagram. DO: 6 practical simulations were carried out for 21 staff on a new triage protocol, the Interagency Integrated Triage tool. STUDY: a tally sheet and observation checklist were implemented, and 2 structured debriefings took place. ACT: The new triage system was established and tested using a walk-through simulation.

RESULTS
Simulation deepened the problem analysis and helped define improvement plans in: space design; processes; team composition; task distribution; material; and staff competencies. Although no baseline data was available, post-intervention data showed a highly functional triage system: from 4331 OPD-triaged patients over 30 days there were 59 red cases, 96.6% of whom were identified at triage. From a 25-point observation checklist, staff completed 96-100% of all steps in repeated observations. The team chose to use the same methodology to adapt the triage process for the upcoming malaria peak, even including the community for walk-through simulations and feedback..

CONCLUSIONS
Simulation is a powerful tool that can be used to drive QI processes. Incorporating simulation into the Plan-Do-Study-Act (PDSA) cycle allowed greater participation and depth of analysis by staff and helped to redesign, test and adapt a new triage system.