The Journal of Continuing Education in Nursing

Original Article 

Setting the Foundation for an In Situ Simulation Program Through the Development of a Malignant Hyperthermia Simulation in the Operating Room

Maria Matsco, MSN-Ed, RN; Megan Marich, MSN, RN; Paula Parke, MSN-Ed, RN-BC, CNE


This article reviews the VA Manchester Healthcare System's journey to develop a robust simulation program and how an in situ simulation for malignant hyperthermia (MH) laid the foundation. Nurse educators collaborated with a certified registered nurse anesthetist to develop a simulation in the operating room using our MH protocol, which included the support of the Malignant Hyperthermia Association of the United States. The positive reaction from this in situ training led to additional simulation requests for the education department. [J Contin Educ Nurs. 2020;51(11):523–527.]


This article reviews the VA Manchester Healthcare System's journey to develop a robust simulation program and how an in situ simulation for malignant hyperthermia (MH) laid the foundation. Nurse educators collaborated with a certified registered nurse anesthetist to develop a simulation in the operating room using our MH protocol, which included the support of the Malignant Hyperthermia Association of the United States. The positive reaction from this in situ training led to additional simulation requests for the education department. [J Contin Educ Nurs. 2020;51(11):523–527.]

In 2009, the Veterans Health Administration (VHA) established a national simulation training and education program to improve the health care of its Veterans (VHA SimLEARN, 2019). This state-of-the-art National Center, SimLEARN (Simulation Learning, Education and Research Network), recognizes simulation-based education as an innovative, essential practice for safe, quality care. Highly trained staff in this program teach numerous simulation-based courses to medical professionals from around the country. In addition to building the Sim-LEARN Center, the VHA deployed simulated manikins, voice assisted manikins, and specific task trainers to all the VA Healthcare systems.

In late 2017, the VA Manchester Healthcare System (VAMHS) assembled the high-fidelity manikin, and the nurse educators began taking advantage of the multiple simulation training courses offered at the SimLEARN Center in Orlando, Florida. We learned simulation theory, facilitation, debriefing techniques, and experienced hands-on demonstration using the high-fidelity manikins. This education provided the foundational and experiential knowledge we needed to jump-start our simulation program and promote interest throughout the facility.

The first simulations with continuing education credit were offered during nurses' week 2018 in our simulation laboratory. Offering two different Exploration in Simulation programs, we were surprised to have no attendees. With a lack of staff engagement and simulation not gaining momentum, we looked toward a different solution and approach: bring the simulation experience to the staff.


Simulation has been supported as an effective method for health care training, providing staff with the ability to apply critical thinking and practice hands-on skills in a safe environment (Adib-Hajbaghery & Sharifi, 2017). Nursing education often uses simulation, and it is rapidly changing the health care environment. For this reason, the Institute of Medicine (2010) recommends simulation for staff in the work environment as a means of continuing education to develop new skills and knowledge. Health care simulation is considered an effective method to bridge the gap from theoretical learning to clinical practice, potentially reducing the risk to patients (Martinerie et al., 2018).

Bringing simulation training to the units and providing in situ educational opportunities adds authenticity to the training and can include the interprofessional team. Theilen et al. (2017) found that conducting in situ training for the deteriorating pediatric patient demonstrated improvements in the unit response, leading to a reduced number of pediatric intensive care unit bed days associated with unplanned admissions. This study is specific to pediatric populations, laying the foundation for further research on the effects of in situ simulation in the care of adult populations. Although Sørensen et al. (2017) found there was no significant difference in learning outcomes of in situ versus off-site simulation, specific process improvement opportunities were noted by the in situ groups. In situ simulations can be a highly effective strategy to improve staff communication under challenging situations, such as low frequency, high-risk events.

Why We Chose Malignant Hyperthermia

The certified registered nurse anesthetist (CRNA) approached the nurse educators to collaborate on a malignant hyperthermia (MH) simulation training. This request was the perfect opportunity for us to combine evidence-based education with our desire to trial in situ simulation. Malignant hyperthermia is rare but can be a fatal complication under select circumstances in the operating room (OR) (Rosen et al., 2019). Untreated MH has a mortality rate of 80%, but with prompt recognition and quick treatment, this rate decreases to 5% (Parsons et al., 2019). As MH is a high-risk, low-frequency situation, the health care team must be prepared to recognize and treat an MH event should it occur. In addition to staff education, simulation is an effective adjunct to training, providing a hands-on opportunity for clinicians to practice their skills and knowledge in a supportive environment. Simulation also has the benefit of increasing crisis management skills and improving knowledge retention, which is critical in an MH situation (Parsons et al., 2019).


The anesthesia staff at the VAMHS provide staff instruction and treatments needed if an MH event should occur. After providing recent education on MH, a CRNA looked to the nurse educators for a real-life practice experience. During the initial planning meeting, we reviewed the VAMHS process. Because our process follows the Malignant Hyperthermia Association of the United States (MHAUS) protocol, we decided to incorporate the live MHAUS hotline during the simulation.

We contacted MHAUS to inquire about the feasibility of calling the hotline during our training. As a mock call program is available through MHAUS for a fee, we incorporated the call into the simulation. The next step was to schedule a date, time, and location, which can be a challenge when planning in situ simulation. As an MH drill needs to be performed in an OR suite, we needed approval from the OR manager. The timing had to be negotiated since the OR would not only need to be available for the simulation but would also need cleaning after the simulation. The VAMHS OR typically has a late start on Wednesday mornings; therefore, Wednesday was chosen to prevent disruption of patient care. The date and time were coordinated with MHAUS.

Next, we needed to construct a simulation scenario and program our high-fidelity manikin. One challenge faced was enlisting the CRNA for simulation plan development. Although he initially approached us to conduct an MH drill, his schedule did not allow time to commit to the simulation development. We researched information on MH drills, developed the scenario, and then met with him to review the plan. In collaboration with the CRNA, we outlined the physiological changes that occur during an MH crisis. The high-fidelity manikin was programmed to correspond with the changes in patient condition. We programmed multiple options for vital signs and electrocardiogram rhythms for use during the scenario. The options would allow for participants to make treatment decisions based on the changing patient condition. After the programming was complete, we practiced the simulation with the CRNA to ensure the proper functioning of the equipment and correct sequencing of the simulator's changes.


On the day of the MH training, the high-fidelity manikin was brought to OR #2 at 7:30 a.m. for setup. The manikin was placed on the OR table for draping and prepping and was intubated for the simulated surgical procedure. The staff scheduled for the OR that day were asked to go into the OR as a case would be starting momentarily. Staff then realized they were taking part in a simulation. This simulation was unannounced to the frontline staff, but the CRNA did invite upper management.

As the OR case began, the staff assumed their usual roles. We ran the simulation equipment, recorded the events in real time, and observed the simulation. As staff noticed the patient's changing vital signs and changing status, assistance was requested. The MHAUS protocol was initiated, including the call to the MHAUS hotline. Table 1 demonstrates the simulation progression.

Detail of Actions During Malignant Hyperthermia Simulation

Table 1:

Detail of Actions During Malignant Hyperthermia Simulation


After the training was complete, we conducted a debrief of the simulation. Per Sherwood and Francis (2018), “Debriefing has been identified as the single most important design feature in enhancing learning outcomes during simulation” (p. 82). The debriefing questions are provided in Table 2. Comments from staff included appreciating the drill and feeling that the hands-on approach allowed them to simulate how an actual MH scenario might transpire. Skills and knowledge gained included how to call for help, where to find essential supplies (including the MH cart), and essential staff roles during an MH crisis. Staff were able to experience real-time assistance from the MHAUS hotline and simulate a high-risk situation. During debriefing, the team mentioned they initially experienced some confusion when MHAUS requested their name, facility, email, and telephone number. This request caused a slight delay in the drill while providing the information. Using the MHAUS hotline was an excellent opportunity for staff as they learned what information MHAUS requires for any call.

Debriefing Questions

Table 2:

Debriefing Questions

Simulated training opportunities not only provide beneficial hands-on experience for infrequent medical events but reveal opportunities to correct processes that cause delays. The unexpected information request from MHAUS caught staff off guard and scrambling for information while the patient was critical. The staff now keep this demographic information next to the OR telephones so they can provide the information to MHAUS without hesitation or delay in patient care.

Another unexpected process issue was the requirement of anesthesia staff to accompany the patient during transport to a higher level of care. As VAMHS is a small ambulatory facility, this requirement identified the need to review our protocol and to ensure coverage for all patients during an MH crisis.

In addition to the debrief, the participants completed an online postsurvey. The results were congruent with our simulation debrief. Staff found it most helpful to participate in an “actual simulation and call the MH hotline.” When asked what attitudes, strategies, or skills related to interprofessional collaborative practice they experienced, responses included statements such as “it was good to see the flow of events” and “roles that different staff would take in the event of a true MH crisis.” Many comments emphasized the importance of teamwork in this simulated crisis setting.

Completing in situ simulation training was effective in providing hands-on practice and allowed us to evaluate the facility's current processes. Debriefing the event helped solidify what was learned and how to improve the process. As this was the first time upper management had seen simulation training at VAMHS, they expressed how impressed they were with what could be accomplished with the simulation equipment and the effectiveness of the training. They also were impressed at how serious the staff performed during the simulation, collaborating, and communicating to resolve the event. The nurse executive highlighted the success of this simulation for the facility in her quarterly newsletter and posted it on the facility's intranet home page.


Simulation is an effective, interactive, and collaborative teaching tool that can be used in diverse clinical settings, demonstrating positive outcomes. Simulation not only allows hands-on training for staff but often can uncover process issues that need to be reviewed, changed, and or improved. After the MH simulation was completed, there was such positive feedback from staff and administration that we began receiving requests for further simulated training from other units. A significant contributor to our success was getting the support from the administration to promote simulation throughout the facility. Meeting the learners in their practice setting was the steppingstone that sparked interest and created simulation momentum at our facility. Since the MH simulation, we have completed simulation training in our community living center for fall prevention and medication interruption, the specialty clinic for suicide awareness and anaphylaxis, and same-day surgery for cardioversion training. Involving stakeholders in the planning process can ensure success in capturing the audience and having a space to conduct the in situ simulation. We continue to stay steadfast in meeting our educational challenges and bringing simulation to staff to improve patient care outcomes.


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Detail of Actions During Malignant Hyperthermia Simulation

8:00 a.m.Simulation began: Staff introductions, prebrief, and staff directed to remain in usual OR roles for simulation case
8:02 a.m.Patient intubated and monitored, staff preparing to begin OR case
8:02–8:04 a.m.CRNA starts noting trending changes in VS and CO2 level
Baseline VS: HR = 80 bpm, BP = 120/80 mmHg, RR = 12 bpm, O2 sat = 98% sat, T = 99.0°F, ETCO2 = 34 mmHg
Trending VS: HR = 120 bpm, BP = 90/60 mmHg, RR = 24 bpm, O2 sat = 93% sat, T = 100.6°F, ETCO2 = 55 mmHg
Signs of MH recognized
Requested circulating RN call for assistance through intercom system
8:04 a.m.CRNA manually ventilating patient
Second large bore IV established
Assistance from OR and PACU arrived
Anesthesiologist arrived
VS continue trending over next few minutes, HR = 126 bpm, BP = 80/50 mmHg, RR = 30 bpm, O2 sat = 90% sat, T = 104.3°F, ETCO2 = 70 mmHg
CRNA requested calls to MHAUS and 911
8:05–8:07 a.m.Call to MHAUS hotline by CRNA and anesthesiologist
Call placed on speaker phone, MHAUS requesting caller's name, facility, phone number, and email address
PACU RN called 911 and provided traffic control
Anesthesiologist communicating with MHAUS
Anesthesia discontinued
OR staff start cooling patient
Foley catheter inserted
Updated VS: HR = 116 bpm, BP = 92/60 mmHg, RR = 22 bpm, O2 sat = 93% sat, T = 103.9°F, ETCO2 = 55 mmHg
8:10 a.m.Instructions from MHAUS include:
Draw and send labs (arterial blood gas and potassium)
Administer 50 mEq sodium bicarbonate for acidosis and ventricular arrhythmias observed
Administer Ryanodex® 2.5 mg/kg (for a 70-kg patient, this is 175 mg, which is a 4–5 mL IV push)
Manually ventilate patient
BP still low, instructed to give 1 gm calcium chloride
8:16 a.m.Nurse educators stated arrival of emergency medical technicians
MHAUS instructed to ensure patient stabilized and have CRNA accompany patient with extra dose Ryanodex in ambulance
Transfer process simulated to nearest emergency department and report to accepting facility stat
8:20 a.m.Simulation ended

Debriefing Questions

How do you feel about this scenario?

What led initial staff to determine MH crisis?

What went well?

What could be improved?

What gaps did you identify in your own knowledge?

How well did the team work together?

Final thoughts?


Ms. Matsco is REdI Director and Nurse Educator, and Ms. Marich is Nurse Educator, VA Manchester Healthcare System, Manchester, New Hampshire; and Ms. Parke is Transition to Practice Program Director and RN Clinical Instructor, VA Bedford Healthcare System, Bedford, Massachusetts.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank John McNemar, DNAP, CRNA, for his expertise and assistance in coordinating this simulation and Kim DeMasi, DNP, RN, LADC, for her support and encouragement in developing a simulation program at the Manchester VA Medical Center.

Address correspondence to Maria Matsco, MSN-Ed, RN, REdI Director and Nurse Educator, VA Manchester Healthcare System, 718 Smyth Road, Manchester, NH 03104; email:

Received: February 26, 2020
Accepted: June 08, 2020


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