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Towards the Next Frontier for Simulation-Based Training: Full-Hospital Simulation Across the Entire Patient Pathway

Arora, Sonal PhD*; Cox, Charles MBBS; Davies, Simon MSc; Kassab, Eva MSc*; Mahoney, Peter PhD§; Sharma, Eshaa MBBS*; Darzi, Ara MD, FACS*; Vincent, Charles PhD*; Sevdalis, Nick PhD*

doi: 10.1097/SLA.0000000000000305
Original Articles

Objective: To evaluate the efficacy of an entire hospital simulation in imparting skills to expert healthcare providers, encompassing both retention and transfer to clinical practice.

Background: Studies demonstrating the effectiveness of simulation do not concentrate upon expert multidisciplinary teams. Moreover, their focus is confined to a single clinical setting, thereby not considering the complex interactions across multiple hospital departments.

Methods: A total of 288 participants (Attending surgeons, anesthesiologists, physicians, and nurses) completed this largest simulation study to date, set in the UK Defence Medical Services' Hospital Simulator and the conflict zone in Afghanistan. The simulator termed “Hospital Exercise” (HOSPEX) is a fully immersive live-in simulation experience that covers the entire environment of a military hospital with all departments. Participants undertook a 3-day training program within HOSPEX before deployment to war zones. Primary outcome measures were assessed with IMPAcT (the Imperial Military Personnel Assessment Tool). IMPAcT measures crisis management, trauma care, hospital environment, operational readiness, and transfer of skills to civilian practice. Reliability, skills learning, and retention in the conflict zone were assessed statistically.

Results: Reliability in skills assessment was excellent (Cronbach α: nontechnical skills = 0.87–0.94; environment/patient skills = 0.83–0.95). Pre/post-HOSPEX comparisons revealed significant improvements in decision making (M = 4.98, SD = 1.20 to M = 5.39, SD = 0.91; P = 0.03), situational awareness (M = 5.44, SD = 1.04 to M = 5.74, SD = 0.92; P = 0.01), trauma care (M = 5.53, SD = 1.23 to M = 5.85, SD = 1.09; P = 0.05), and knowledge of hospital environment (M = 5.19, SD = 1.17 to M = 5.42, SD = 0.97; P = 0.04). No skills decayed over time when assessed several months later in the real conflict zone. All skills transferred to civilian clinical practice.

Conclusions: This is the first study to describe the value of a full-hospital simulation across the entire patient pathway. Such macrosimulations may be the way forward for integrating the complex training needs of expert clinicians and testing organizational “fitness for purpose” of entire hospitals.

Supplemental Digital Content is Available in the Text.The current evidence on simulation is limited to single clinical settings. This is the first study of an entire hospital simulation encompassing experienced team members interacting across every stage of the patient pathway. It demonstrates that such macrosimulations can be effectively used to improve technical, nontechnical, and organizational skills among expert health care providers.

*Department of Surgery and Cancer, St Marys Hospital, Imperial College London, London

The Royal Wolverhampton NHS Trust, Wolverhampton, West Midlands

University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire; and

§Royal Centre for Defence Medicine, Birmingham, United Kingdom.

Reprints: Sonal Arora, PhD, Department of Surgery and Cancer, St Marys Hospital, Imperial College London, London W2 1NY, United Kingdom. E-mail:

Disclosure: Supported by the National Institute for Health Research (NIHR) and the Economic and Social Research Council (ESRC), UK. There was no specific funding for this research. The authors declare no conflicts of interest. The funders had no role in any aspect of the study.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

© 2014 by Lippincott Williams & Wilkins.