title: Towards the next frontier for simulation-based training: full-hospital simulation across the entire patient pathway.
abstract: 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.
authors.affiliation: *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.
authors.forename: Sonal
authors.initials: S
authors.lastname: Arora
authors.forename: Charles
authors.initials: C
authors.lastname: Cox
authors.forename: Simon
authors.initials: S
authors.lastname: Davies
authors.forename: Eva
authors.initials: E
authors.lastname: Kassab
authors.forename: Peter
authors.initials: P
authors.lastname: Mahoney
authors.forename: Eshaa
authors.initials: E
authors.lastname: Sharma
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Charles
authors.initials: C
authors.lastname: Vincent
authors.forename: Nick
authors.initials: N
authors.lastname: Sevdalis
mesh_terms: D000293:Adolescent; D000328:Adult; D002983:Clinical Competence; D003430:Cross-Sectional Studies; D005260:Female; D006739:Hospital Administration; D006752:Hospital Planning; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D008887:Military Medicine; D010348:Patient Care Team / Q000458:organization & administration*; D016544:Patient Simulation; D015397:Program Evaluation; D011446:Prospective Studies; D006113:United Kingdom