International Journal of Healthcare Simulation

Background:

A 73-year-old patient underwent an anterior cervical discectomy and fusion (ACDF) procedure at our Trust. During the procedure, the patient unfortunately experienced three discreet episodes of accidental awareness under general anaesthesia. The patient subsequently experienced significant psychological morbidity in the form of post-traumatic stress disorder. Accidental awareness under general anaesthesia has an estimated incidence of approximately 1:19,000 anaesthetics. Longer-term psychological effects have been shown to affect approximately half of all patients reporting accidental awareness ^[¹ ^]. In this case, the affected patient felt strongly that they wanted their experience to be utilised to support learning activities for anaesthetic practitioners, with the clear aim of preventing further patient harm. They therefore gave permission for their precise encounter and recollections to inform realistic simulation-based educational exercises, particularly to enable powerful informed debriefing.

Methods:

Using qualitative data gathered during interviews undertaken by the Recovery from Critical Illness team, who include psychological support services, we have developed a dual simulation-based educational session aimed at anaesthetists in training and student operating department practitioners. The first scenario aims to increase practitioner recognition of this potential complication of anaesthesia by realistically simulating intraoperative manifestations of awareness. The second scenario aims to improve immediate follow up and support for an affected patient, informed by our patient’s lived experience and powerful recollections of this disastrous event. We have combined these simulations with structured training on Total Intravenous Anaesthesia (TIVA), with particular focus on the 2019 Association of Anaesthetists guidelines ^[² ^]. In doing so, we aim to ensure participants were equipped with knowledge and skills relating to local equipment and monitoring options, with the intention of minimising the risk of accidental awareness for future patients.

Findings:

The affected patient has endorsed the simulation exercise and has expressed their hopes that their case can be used effectively to improve practitioner cognizance, particularly relating to the psychological impact of accidental awareness. We plan to share details of this simulation exercise with other hospitals within the Deanery via our simulation network, using participant feedback to refine the session content and format of delivery.

Conclusion:

Using a patient’s lived experience to inform simulation exercises can add a powerful dimension to improve realism within simulation-based education, and to optimise informed and accurate debriefing. This is particularly important when reflecting the psychological impact of patient safety incidents on affected individuals.

References

1. Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O’Connor K, O’Sullivan EP, Paul RG. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. British journal of anaesthesia. 2014;113(4):549–559.

2. Nimmo AF, Absalom AR, Bagshaw O, Biswas A, Cook TM, Costello A, Grimes S, Mulvey D, Shinde S, Whitehouse T, Wiles MD. Guidelines for the safe practice of total intravenous anaesthesia (TIVA) joint guidelines from the association of anaesthetists and the society for intravenous anaesthesia. Anaesthesia. 2019;74(2):211–224.