International Journal of Healthcare Simulation

Introduction

Postoperative neck haematomas have a reported incidence of 2.4%–3.4% [1,2]. They have been described after thyroid, laryngeal, carotid and cervical spine surgery [1–4]. Postoperative neck haematomas carry significant patient morbidity and mortality; they often occur in the neck’s deep fascial layers, which can make them difficult to identify at the bedside. Major airway compromise can result from direct compression by haematoma, impaired venous drainage in the region and concomitant airway oedema. Postoperative neck haematomas result in longer hospital stays, higher costs and a higher mortality rate [1]. The Difficult Airway Society, British Society of Endocrine and Thyroid Surgeons, and Ear Nose and Throat Surgery United Kingdom (ENT UK) published consensus guidelines providing an algorithm for the management of suspected neck haematoma following thyroid surgery. As part of their recommendations, they advise that all clinical staff interacting with these patients are trained to recognize the potential symptoms, signs and subsequent management [5]. The guidelines also suggest introducing a post-thyroid surgery haematoma evacuation kit for emergency use which should be immediately available at the patient’s bedside. We believe such principles should be targeted towards post-thyroidectomy neck haematomas, but they can be broadly applied to other surgeries where there is a risk of a postoperative neck haematoma.

Simulation training has become a common form of clinical training in recent years. It is a valuable method of training as it allows trainees to gain exposure to clinical scenarios in a controlled and safe environment. Simulation training improves technical skills and teamwork [6,7]. It has also been shown to be effective for gaining surgical skills [8,9].

Our aims with this quality improvement process were two-fold. First, to provide education in the form of interprofessional simulation scenarios to all staff providing care to these patients on the otolaryngology surgical ward. The primary aim of this education programme was to improve participants’ confidence and self-assessed competency to recognize the signs and symptoms of a postoperative neck haematoma and to ensure staff were aware of the appropriate escalation protocol in this emergency scenario. Our second aim was to introduce an emergency neck haematoma evacuation kit to accompany all patients who have had a thyroidectomy from the theatre recovery room to the ward and remain by the patient’s bedside for their postoperative stay.

Methods

This quality improvement process was carried out in a high volume, tertiary referral, head and neck cancer centre, receiving 60%–70% of all referrals nationally. Institutional approval was sought and granted for the project.

We created a simulation scenario detailing learning objectives, necessary equipment and simulation staff, scenario development, patient behaviour, and suggested points for discussion at debrief (Appendix A). Simulation training scenarios were held on the otolaryngology (ENT) postoperative surgical ward and were led by a Consultant Anaesthetist with a special interest in complex airway management and simulation training. The ward’s Nurse Manager reviewed the questionnaire and scenario before the series of training sessions were commenced. A high-fidelity manikin (SimMan Essential, Laerdal Medical, Stavanger, Norway) was used for the scenario. Four simulation training sessions were performed over the course of 4 days, with nurses from the main ENT and maxillofacial postoperative surgical wards and surgical interns as participants. In total, 50 participants attended or took an active role in the simulation sessions. We carried out qualitative questionnaires before and after the sessions. These were developed with consideration of the learning objectives (Appendix A) and with the aim of the assessment of; training; experience; knowledge; familiarity with management; attitudes.

A brief was provided to participants explaining that they should treat the SimMan like a normal patient, apply monitors as they would for patients, assess and examine the SimMan and take actions like they would for any patient. A facilitator (Post Anaesthesia Care Unit nurse) would give their standard postoperative handover to the participant (ENT ward nurse) for a well post-thyroidectomy patient (see an example in ‘Clinical Case Information’ in Appendix A). The scenario progressed from evaluating a well patient to a clinical deterioration from an airway perspective. At this point, a neck haematoma was added to the SimMan (Figure 1). Participants were encouraged to follow the steps they would normally follow in this scenario including calling appropriate team members to review the patient. Surgical interns were called as active participants to review the patients and real-time calls were made to ENT surgeons performing their regular duties in other areas of the hospital. The brief was to manage the scenario as it evolved. Emergency neck haematoma boxes were provided for the scenarios along with the recently published guidelines [5]. Prompts were provided as required and the scenario was allowed to progress until an ENT or anaesthesiology registrar had arrived to evacuate the neck haematoma and organized safe transfer of the patient to theatre. When the simulation ended an overview of the case management and debriefing was carried out using the plus/delta approach discussing what was done well or could have been done differently. At this point, post-simulation questionnaires were filled out.

Figure 1:

Manikin demonstrating haematoma between superficial and deep layers of sutures.

A sample neck evacuation kit was created and used for the simulation scenarios. This was created using a simple clear box and some equipment from theatre. The contents of this kit are listed in Table 1. An introduction to the scenario was given to participants and they were given the opportunity to ask questions and to examine the manikin and neck evacuation kit before the scenario began (Appendix A details the clinical case and ‘scenario start’ information which was provided).

Table 1:

Contents of neck evacuation kit

Contents of neck evacuation kit
Scalpel Scissors Sterile gauze Artery clip Management of suspected neck haematoma guidelines SCOOP guideline (i.e. guideline with steps on how to evacuate the neck)

Results

Pre-simulation questionnaire results

The questionnaires completed before the simulation training session showed that only 6.7% of staff had seen a neck being evacuated on the ward. 37% had received prior teaching on the management of neck haematomas. 83% felt they would recognize the signs and symptoms of a postoperative neck haematoma, but only half stated that they knew what action to take in this situation (Table 2). All respondents said they would be interested in attending a simulation training session.

Table 2:

Questions asked pre- and post-simulation training

Questions asked before and after simulation training	Pre-sim responses	Post-sim responses	p Value* (CI)
Do you know symptoms and signs of a neck haematoma?	38 (83%) Yes	50 (100%) Yes	0.002 [0.72–0.943]
Do you feel you know what to do if you think someone is developing a neck haematoma?	22 (48%) Yes	50 (100%) Yes	<0.001 [0.354–0.647]
Would you feel confident evacuating a neck haematoma if you had to yourself?	5 (11%) Yes	33 (67%) Yes	0.052 [0.110–1.040]

*Pearson chi square.

Respondents were also asked about their attitudes towards introducing a post-neck surgery haematoma evacuation kit. 100% feel that introducing a neck haematoma evacuation kit is necessary, and all felt that the kit would improve patient outcomes.

Discussion

The incidence of Head and Neck Cancer (HNC) is rising annually, with a predicted 30% increase in the number of new cases by 2030 [10,11]. Therefore, we must provide frequent formal training for staff on the management of potential complications of HNC surgery. This study shows that simulation training can significantly improve the confidence of healthcare staff in recognizing and implementing appropriate management of postoperative neck haematomas. This is important as it suggests that simulation training has the potential to improve clinical care.

The pre-simulation questionnaire demonstrated that only a small number of staff had previous experience with evacuating a neck haematoma. This was not surprising as we know it is uncommon, but it also reflects the attendance of more junior staff (interns) with less clinical experience. Only one-third had previous training on this topic, which is surprisingly low given the amount of head and neck surgery in the hospital.

The simulation training sessions resulted in more participants being able to identify the signs and symptoms of a neck haematoma and more participants feeling confident they know the necessary action required in this situation. Furthermore, four times as many respondents said they would feel confident evacuating the haematoma themselves if required, compared to responses before the simulation. These results show the positive impact of simulation training and provide a basis for advocating for this training to continue on a regular basis. Successful management of a neck haematoma after staff simulation training has been described in the literature [12].

This study provides insight into the attitudes of healthcare staff towards simulation training. It was clear from the responses given that healthcare staff feel insufficient time and resources are dedicated to providing efficient clinical professional development. Staff responded positively towards the training incorporated into this study. Another theme identified from responses was; the recognition of the deteriorating patient. Participants selected this as one of the most crucial aspects of education and the most satisfying for targeted improvement.

Our training demonstrates that simulation works to increase participants’ confidence and familiarity with a given situation. Another study involving simulation with the use of a task trainer for evacuation of a retrobulbar haematoma also showed that simulation training acted to increase participants’ confidence in management [13]. Simulation-based training is now well-established as a method for effective, high-yield teaching. Simulation-based training has been shown to be more effective than didactic teaching when teaching doctors how to deal with various acute patient scenarios [14,15]. As well as technical skills, a small RCT of simulation training for non-technical skills in crisis resource management has shown that the learning from the scenario was unchanged between active participants and observers [16].

‘High-fidelity’ simulators have been developed in recent years. This term has emerged from the need to distinguish between mannikins that contain more advanced technology and thus provide a greater degree of realism, to mannikins which do not provide any advanced features. This study involved a high-fidelity simulator, that is, a mannikin which is remotely controlled by a computer, or which can simulate patient noises or movements. However despite the increasing development, expense, and interest in high-fidelity mannikins, the literature suggests that low fidelity simulators are non-inferior to high-fidelity simulators, with one study even suggesting that high-fidelity simulators can lead to overconfidence among students [17,18].

Debriefing is a key part of the learning process in simulation [19,20]. We took a plus/delta approach to debriefing for this project. This method encourages the learner to reflect on one’s own performance, as well as the overall team performance [21]. Learners are asked ‘what went well’, ‘what did not go well and why’, and ‘would you do anything differently next time’. The plus/delta method promotes teams to reflect on their performance, which can enhance teamwork through shared models of thinking [22]. Thus, it felt appropriate for this scenario as it involved participants who work together on a team basis daily.

There was unanimous support for the introduction of the post-neck surgery haematoma evacuation kits, with all participants stating it could potentially improve patient outcomes. The need for the availability of emergency equipment at the bedside has been recommended and implemented for several different clinical scenarios. For example, it is common practice for patients with new tracheostomies to have an emergency tracheostomy kit at their bedside, as the National Tracheostomy Safety Project recommended [23].

This study has many strengths. It focused on the education of staff in an area of great importance and may help to reduce future patient morbidity and mortality. It involved pre- and post-simulation questionnaires allowing us to compare before and after. The second aspect of the study, the introduction of a neck haematoma evacuation kit, is supported by recently published guidelines [5]. However, there are also several limitations to our study. This was a single-centre study. It had a small number of participants. Finally, we have no evidence that this education will impact patient care.

We suggest that simulation-based training for this infrequent high-risk clinical scenario should occur at regular intervals to maintain staff competencies. A previous study which compared six weekly to six monthly repetitions of simulation, showed higher technical and non-technical scores in the 6-week group [24]. However, the frequency of simulation repetition must be balanced against the practicalities of providing this in a busy tertiary hospital environment.

We recommend that training on neck haematomas and their management should form part of a medical student’s teaching in their final year and this training should be repeated during intern induction. Similarly, all doctors rotating through the ENT team and nurses working on post-op surgical wards should attend a simulation scenario on neck haematomas as part of the job. We recommend introducing neck haematoma evacuation kits as part of the postoperative plan for patients having any form of neck surgery. We believe these kits should accompany the patient from the recovery room to the ward and remain at the patient’s bedside until discharge. Future studies into which patients are more likely to develop a haematoma would be welcomed. This may allow patients to be risk stratified and their postoperative care location could be based on their risk.

In conclusion, we have demonstrated the introduction of emergency neck haematoma evacuation kits for all patients undergoing thyroidectomy and we successfully introduced a simulation teaching programme to assist staff in the management of this emergency scenario.