Demographics

Four nurses, seven allergy-immunology fellows and six allergy/immunologists (17 participants) underwent the simulation. Among the fellows, 4 (57%) were starting their allergy-immunology training, and 3 (43%) had more than one year of training. The participants’ demographic characteristics are shown in Table 1. Most participants (59%) had little experience in simulation. Two participants reported that they were managing more than 20 anaphylactic reactions per year, while the majority (65%) managed between 1 and 10 anaphylactic reactions per year.

Table 1 Demographic characteristics (N = 17)Questionnaires

Overall, the simulation experience was positively rated on the 5-point Likert scale, with most participants agreeing that the themes matched their learning objectives and that the level of difficulty was adequate (Fig. 3). Also, 94% (16/17) of the participants considered that the scenarios were representative of what could occur in a clinical setting and eight (8/17, 47%) indicated that they were able to focus during the simulation activity. Eight participants expressed that the simulation activity allowed them to reproduce the same “feelings” they had while managing a severe anaphylactic reaction. Most participants thought that the activity allowed them to identify their strengths (82%) and weaknesses (88%) and to improve their teamwork skills (94%). However, despite steps taken to create a safe learning environment lacking judgment, four participants found the simulation training stressful, and one person indicated feeling somewhat uncomfortable discussing their performance in the group debriefing session. All participants agreed that this activity should be mandatory for all allergy clinic personnel. Three participants spontaneously suggested that this activity should be done once a year to maintain competency.

As can be observed in Fig. 2, after completing the simulation-lab activity, participants showed a significant improvement in their confidence in managing all aspects of acute anaphylaxis except for “code blue” management. The absence of progress for the latter was partly explained by the fact that most of the allergy-immunology fellows, who had recently completed their internal medicine training, considered that their knowledge of code running was appropriate before the activity. One participant indicated lower confidence in performing high-risk challenges and leading a code following the high-fidelity simulation. This same participant suggested that the training met his objectives and should be mandatory.

Finally, in the open questions section, 76% of the participants wrote comments and suggestions indicating that the activity's main strengths were its realism, comprehensive objectives, immediate personalized debriefing, and team-building advantages. Thus, most of the written comments about the experience were positive such as “helped increase my knowledge”, “good scenarios”, and “realistic environment”. The main improvements suggested were that it should be repeated (“minimally once a year”) and that it should last longer and have additional scenarios.

In situ simulation and impact on code blue management at the allergy clinic

The in-situ simulation revealed gaps in the process, especially regarding rapid access to medication and material, code signalling, code team response and crash cart transport. During this practice, a nurse mentioned missing some acute management drugs. A major problem identified was that the code signalling for the outpatient clinic needed to be relayed by multiple intermediates and dispatched to various buildings. During the simulation, the code signalling was never heard in the building where the allergy clinic is located, leading to a significant delay in the crash cart’s arrival. This problem was uncovered during the simulation and resolved with the help of the security team.

In a real code blue management four months after the simulation, the gaps mentioned had been resolved. Notably, access to the medication and the material had been facilitated by adding clear written indications on the walls on where to find different drugs and equipment. A log designed for allergy medication and equipment was added to the acute care room to optimize availability, space and access. New posters indicating how to prepare some rarely used drugs were also added. During the simulation, the recorded time to receive the cart transport was 12 min. During the actual code at our clinic, this delay was reduced to 1 min, representing a 92% improvement.

InterviewSimulation activity

Participants generally agreed that the simulation was a good training activity that allowed them to improve anaphylaxis management in real life and helped them feel more comfortable with diagnosis and interventions in various situations. They agreed that the simulation environment was similar to what they knew from the adult allergy clinic, even if most allergy-immunology fellows (4/5) had not had the chance to manage anaphylaxis before the simulation. They appreciated the practice environment and the quality of the material available, as well as being able to have a hands-on approach. Table 2 summarizes the participant’s positive feedback, identified gaps, and narrative comments.

Table 2 Summary of qualitative interviews

Some nurses found it more difficult to naturally fill their roles because of the equipment available and the specificities of handling the mannequin. This comment was echoed by one of the allergy-immunology fellows, who mentioned the limitations of the mannequin in simulating clinical signs of anaphylaxis. Despite these limitations, the activity was appreciated, and there was a consensus that the activity increased confidence and reassurance in the allergy clinic.

The participants underlined essential elements of team-building. It was felt that the simulation helped the team to “learn to work together.” It clarified expectations and therefore helped team members to trust one another. This was made possible by the safe environment provided by the simulation, where participants felt comfortable making mistakes.

Code blue management

Overall, the interviews revealed that simulation-based training led to more rapid and orderly responses and improved confidence in the participants’ abilities and colleagues’ abilities in managing anaphylaxis. During the actual code blue management, the team was able to stabilize the patient and improvement was noted in various aspects of the process compared to the in-situ simulation. The physician and nurses involved in the code felt an improvement in the team dynamic and physical environment following the simulation-based training. The managing physician added that he considered that the training should be done annually for the physicians and the staff because of the paucity of severe refractory reactions.

Management of other real-life anaphylaxes in the clinic

Regarding anaphylaxis management, a nurse found that the team had sometimes been “disorganized” during the simulation. Still, during a subsequent reaction in the clinic, this same participant indicated that “everything was methodical, and everyone’s role was clear.” One of the physicians echoed this, who mentioned that the staff was “very calm” when managing mild to moderate anaphylaxis.

Three allergy-immunology fellows also mentioned feeling more structured and confident in recognizing anaphylaxis and administering epinephrine. They also agreed that, in general, the staff was “efficient,” “the medication was easily accessible,” and that the health professionals and patients were “more confident and reassured” when confronted with an anaphylaxis reaction.

DiscussionKey findings

Critical care simulation in anaphylaxis at our center allowed participants to identify their strengths and weaknesses and improve their teamwork skills. By conducting post-activity questionnaires and interviews, participants indicated an improvement in several aspects of crisis and anaphylaxis management. The simulation identified a critical gap regarding code blue signalling in the new building and other gaps in the process, such as access to drugs and materials, which were later improved. Overall the activity was very much appreciated, and the participants considered that it should be a mandatory yearly training opportunity.

Previous studies

Similar reports targeting medical and administrative personnel from the community and hospital-based allergy clinics have assessed teaching and retention of emergency management team skills using high-fidelity mannequins, standardized patients and, 10–12 months after the activity, an unexpected in situ simulation [1, 15]. These studies showed improved team management skills in areas such as teamwork and situation awareness, as well as retention of knowledge and abilities after an initial anaphylaxis scenario workshop [15]. Similar studies focused on implementing and using an anaphylaxis and allergy-immunology emergencies simulation curriculum for allergy-immunology trainees [15, 16].

The literature on multidisciplinary team dynamics in anaphylaxis is scarce. In one of the studies mentioned above, the authors focused on the importance of engaging the medical and non-medical personnel to clarify their specific roles to avoid confusion and repetition [1]. In our study, the non-medical personnel were also present during the in-situ simulation allowing them to witness a severe anaphylaxis management scenario firsthand. In the more general acute settings such as the emergency department, the operating room and the intensive care unit, there has also been an interest in characterizing team-based simulation [5]. A review paper including 17 studies underlined the importance of this team training program model aimed at increasing authenticity and improving patient care at an administrative level [5].

Similarly, a systematic review of 38 articles on simulation activities, including 22 randomized controlled trials, found that individual and team performances were improved during critical events and complex procedures [17]. Our results showed a perceived improvement in crisis team management, and 94% of the participants considered that this activity allowed them to improve their teamwork skills. These essential team-building elements were also reported during the interviews. Similarly, medical education programs should focus on developing simulation training to ensure teamwork skill-building through practice and repetition [3, 18].

The questions concerning participants’ confidence before the activity revealed that some staff members had insecurities regarding the appropriate management of anaphylactic reactions. We showed that confidence could improve after simulation training. This was also reflected in the interviews, where participants reported an improvement in their own and other staff members’ ability to manage anaphylaxis. Some studies focusing on emergency responses shared similar conclusions with statistically significant improvement in participants’ confidence after a simulation scenario [19, 20]. One participant reported decreased confidence in code management or performing high-risk challenges. In light of other answers given by the same participant, this seems to be explained by the discovery of unsuspected knowledge gaps, which led the participant realizing that they were not as performant as they would have liked.

The in-situ simulation proved essential for identifying and solving gaps in the process that could not be captured during lab simulation (access to material and medications, code signalling, and intensive care response). The main benefits of an actual medical setting simulation described in the literature are the possibility to evaluate participants’ knowledge and competencies and the clinical environment to improve patient safety [4, 5, 7].

Limitations

This study has limitations. It was performed in a single institution with a limited number of participants. Implementing this type of simulation in other allergy clinics requires considering numerous factors, such as clinic space, material distribution, and staff experience, which are expected to vary between centers. Access to a high-fidelity simulation lab and costs are essential barriers that could prevent the reproducibility of the activity. Here, the recent clinic relocation was used to justify the need for the activity. While all agree that patient safety is paramount, it must be clarified to what extent improved team functioning, efficiency and quality of care resulting from the activity can offset the costs of a simulation-based training. Another significant limitation is that the conclusions of this article are based on a qualitative assessment of the participant’s perceptions.

Furthermore, the perception of confidence should have ideally been measured before and after the intervention. In our study, this was measured following the intervention, which could bias participants’ responses. It did not objectively demonstrate improvements in patient outcomes attributable to the activity, which would have required a prospective experimental design looking at patient outcomes or crew resource management skills assessed by an external observer [21]. Quantifying the value of this qualitative benefit represents an important area of future research [17].

Implications

In an era where virtual reality is increasingly used as simulation technology, it is essential to describe our simulation program’s success and underline its benefits for inter-professional collaboration and patient care.

Conclusion

This study provides critical qualitative data supporting the positive impact of a high-fidelity anaphylaxis training activity on anaphylaxis management in the clinical practice. Participants deemed the activity instrumental in improving staff readiness and decreasing reluctance to perform challenges or procedures at high risk of anaphylaxis in the ambulatory setting. It provides further evidence that high-fidelity simulations should be included in the continuous medical education curriculum for allergy-immunology specialists to improve patient safety and team confidence. Other studies are required to guide best teaching practices using tools such as high-fidelity simulation to manage acute allergic reactions.