Aims Guidelines are often written by experts without heed to real-life use. This is especially problematic for emergency guidelines of infrequent use often out of hours by staff with varying skill mix.
A guideline for safe infusion of concentrated potassium solution was required that was usable across all wards and specialties in a UK children’s hospital. Using improvement methodology we modified one created by experts using video simulation.
Methods The guideline was modified after each PDSA cycle of table top simulation with target users, the doctors and nurses of all skill mixes in their wards. Participants were pre briefed. The nurse role-played from a written scenario and the doctor asked to produce a prescription with the guideline and salient information. Video was used to further understand the process.
An independent observer collected pre-defined measures at each simulation, these included: time taken to prescribe, whether key information was sought by the prescriber and ability to produce a correct prescription. Structural feedback were taken from all participants for their views on the usability and suggestions for improvement for the guideline.
Results The guideline was modified after studying the measures and user suggestions at each simulation. Additional useful information was gained from video study not apparent by direct observation. Modifications made included font size, diagrams, didactic wording, simplification of calculations and table layouts. After five simulation cycles the time taken to prescribe a correct prescription reduced from 22 min to 7 min (figure).
Secondary effect included culture change of involving users in guideline development and a better understanding of the microsystems of our hospital.
Conclusion Simulation can test and improve complex guidelines especially those rarely used in real life regardless of skill mix and hierarchy. Video review adds to information that participants were unaware of or not able to verbalise. Of note, it is time consuming, each simulation and debrief takes upwards of an hour.
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