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© University of Washington Center for Health Sciences Interprofessional Education, Research & Practice 1 Last updated: February 21, 2017
InterprofessionalTeamCommunicationAdult Acute Care Simulation Set‐UpandCurriculumGuide
InterprofessionalTeamCommunicationSimulationSet‐UpandCurriculumGuide........................1
TableofContents............................................................................................................................................................1
GettingStarted.................................................................................................................................................................3
ExampleHalf‐dayAgenda...........................................................................................................................................5
FacultyRequirements..................................................................................................................................................6
CourseName/DesignGroupInfo............................................................................................................................6
Debriefing..........................................................................................................................................................................7
TeamSTEPPSDebrief#1–100LevelSkills.......................................................................................................9
TeamSTEPPSDebrief#2–200LevelSkills....................................................................................................11
TeamSTEPPS/TeamSkillsDebrief#3–300LevelSkills..........................................................................13
TeamSTEPPSGlossary..............................................................................................................................................14
ClinicalScenario:DyspneainaHospitalizedPatient...................................................................................15
Overview...........................................................................................................................................................15
Timeline............................................................................................................................................................16
ScenarioParticipants..................................................................................................................................16
ClinicalOverview..........................................................................................................................................17
IntroductiontoSimulator.........................................................................................................................19
DebriefingTips..............................................................................................................................................21
MedicalTeamHandoffSheet...................................................................................................................22
NursingHandoffSheet................................................................................................................................23
PhilBrown:AdmitHistoryandPhysical............................................................................................24
PhilBrown:InformationforActorPortrayingPhil.......................................................................26
SimulationScenarioRequirementsandEquipment.....................................................................28
Storyboard.......................................................................................................................................................30
DataandResults............................................................................................................................................34
ClinicalScenario:APostoperativePatientwithTachycardia..................................................................36
Overview...........................................................................................................................................................36
Timeline............................................................................................................................................................37
ScenarioParticipants..................................................................................................................................38
ClinicalManagementofUnstableSVTandVT.................................................................................39
IntroductiontoSimulatorandScenario.............................................................................................40
DebriefingTips..............................................................................................................................................42
MedicalTeamHandoffSheet...................................................................................................................43
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NursingHandoffSheet................................................................................................................................43
SurgicalClinicHistoryandPhysicalforPaulSmith.......................................................................44
Equipment.......................................................................................................................................................45
Storyboard.......................................................................................................................................................48
DataandResults............................................................................................................................................51
ClinicalScenario:ATeenagerwithAsthma.....................................................................................................55
Overview...........................................................................................................................................................55
Timeline............................................................................................................................................................56
ScenarioParticipants..................................................................................................................................57
ClinicalOverviewofAsthmaExacerbation.......................................................................................58
IntroductiontoSimulatorandScenario.............................................................................................59
DebriefingTips..............................................................................................................................................61
Micah:HistoryandPhysical.....................................................................................................................62
ERTriageSheet..............................................................................................................................................62
InformationforSimulationTechVoicingMicah.............................................................................63
InformationforActorPlayingMicah’sGrandma............................................................................65
EquipmentandSupplies............................................................................................................................66
PediatricPulmonaryClinicNote............................................................................................................68
Storyboard.......................................................................................................................................................70
PatientLabsandStudies............................................................................................................................75
InterprofessionalTeamCommunicationSimulationSet‐upandCurriculumGuide
© University of Washington Center for Health Sciences Interprofessional Education, Research & Practice 3 Last updated: February 21, 2017
GettingStarted
Purpose:InterprofessionalTeamCommunicationSimulationSet‐upandCurriculumGuide
Thecontentinthisset‐upguidewasdevelopedbytheMacygrantteamattheUniversityofWashington,whowerefundedin2008todevelopandintegrateinterprofessionalteamtrainingintoexistingcurriculumintheHealthSciencesschoolsofMedicine,Nursing,PharmacyandthePhysicianAssistantProgram.
TheinstructionsinthisguideareforLEADINSTRUCTORSsettingupinterprofessionalteamtrainingusingsimulationasthevectorbywhichhealthsciencesstudentscanlearntogethertodevelopandimprovebasic,intermediateandmoreadvancedlevelsofcommunicationskills.TheMacyteamusedTeamStrategiesandToolstoEnhancePerformanceandPatientSafety(TeamSTEPPS)asaframeworkfortheteamcommunicationtraining(seefigure1).
Thefourtrainableteamworkskills/competenciesdescribedinthemodelinclude:1)leadership;2)situationmonitoring;3)mutualsupport;and4)communication.Ahighlyfunctioningteamthatmastersthesecompetenciescanattainthreepossibleteamworkoutcomes:1)performance;2)knowledge;and3)attitudes.
Furtherreading:http://teamstepps.ahrq.gov/teamsteppslogo.htm
Thecontentwaspilotedin2010withagroupof50studentsandthenrolledouttoalargergroupof300+studentsin2011.
ThisguideprovidesthecontentandthestructureusedbytheMacygrantteamtoset‐upandruntheirsimulationscenarios.
Organizationofcontent
Thisguideisorganizedasfollows:
ExampleHalf‐DaySimulationSessionAgenda:UsedbytheMacyGrantTeamwhenconductingtheirteamcommunicationtraining.Dependingongroupsize,simulationscanberunsimultaneouslyorasaprogressiveseriesofsimulations.
FacultyRequirements:ItisidealifatleastoneofthefacilitatorsinthegrouphassomeknowledgeandfamiliaritywithTeamSTEPPS,instructionalbackgroundusingsimulation,andtheclinicalknowledgeneededtorunthescenario.Oftentheinstructorsmayneedtostepinandhelp
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thestudentswithclinicalknowledgeinordertokeepthescenarioontracksostudentscanfocusoncommunicationskillsratherthanmedicalmanagement.
TeamSTEPPSDebriefingGuide:Includesthecommunicationobjectivestocoverinthesimulationsscenarios.Ideally,thecurriculumisdesignedtorunthreescenarios.Eachscenariobuildsoneachotherandprogressesfrombasictomoreadvancedlevelcommunicationskills.
Scenario1:BasicTeamSTEPPSskills(100level)
Scenario2:IntermediateTeamSTEPPSskills(200level)
Scenario3:AdvancedTeamSTEPPS(300level)
TeamSTEPPSGlossary.SummarizesthemostfrequentlyusedTeamSTEPPSconceptsandterminology.TheMacyGrantTeampassedouttheglossarytostudentsduringthesimulationtrainingforquickreference.
SimulationScenarios.TheMacyGrantTeamdevelopedthreesimulationscenarios.
1. ClinicalScenario:DyspneainaHospitalizedPatient2. APostoperativePatientwithTachycardia3. ATeenagerwithAsthma
Eachsimulationscenariosectionincludesthefollowing:
Overview Timeline ScenarioParticipants ClinicalOverview IntroductiontoSimulator DebriefingTips HandoffSheets(ifapplicabletoscenario) AdmitHistoryandPhysical InformationforActorsplayingtherolesofeitherpatientorfamilymember SimulationScenarioRequirementsandEquipment Storyboard DataandResults
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ExampleHalf‐dayAgenda
Note:Simulationsinthissessionwererunsimultaneouslywith3separateinstructorteams
Time Activity Facilitators Materials Needed:
7:30–8:00 AM Students arrive and sign in Front desk/reception
1. Student packets andnametags
8:00–8:50 AM Icebreaker: Paper chain (link to ice‐breaker)(36 students, 6 per group) 1. As a team your goal is to create the longest chain made
out of paper links in 2 minutes, go! a. Quick debrief: What worked? Who emerged asleaders?
2. Now, same goal but you can’t use your dominant handa. How did you work together?
3. Now, you can use any resources in the room, but youcan’t talk
a. Communication and situational awareness?TeamSTEPPS Didactic Presentation Introduce check back, call out, SBAR
TeamSTEPPS facilitator
1. Paper2. Tape dispensers3. Scissors4. TeamSTEPPS Powerpoint
8:50–9:00 AM Explanation of Day, any forms used (eg, observational forms)
1. PPT slides forobservational tool
9:00–9:10 AM Break and transition into 3 groups of 6‐12 Students
9:10–9:50 AM (40 min)
Run Scenario in Groups ‐ Intro (5min) ‐ Content didactic (5min) ‐ Run scenario (15min)
o Group A (6 students) does scenarioo Group B (6 students) observes/has checklist
‐ Debrief (15min)
faculty TBD (pharmacy, medicine, nursing, PA)
1. Simulator & student/staffplaying role of familymember – SVT
2. SP – CHF (patient)3. SP – Asthma (family
member)4. TeamSTEPPS pocket guides5. Clipboards for observers
9:50–9:55 AM Walk from station 1 to station 2
9:55–10:35 AM (40 min)
Run Scenario in Groups ‐ Intro (5min) ‐ Content didactic (5min) ‐ Run scenario (15min)
o Group B does scenarioo Group A observes/has checklist
‐ Debrief (15min)
faculty TBD (pharmacy, medicine, nursing, PA)
SAME AS ABOVE
10:35–10:40AM Walk from station 2 to station 3
10:40–11:20 AM (40 min)
Run Scenario in Groups ‐ Intro (5min) ‐ Content didactic (5min) ‐ Run scenario (15min)
o 6 student volunteers do scenarioo Other 6 students observes/has checklist
‐ Debrief (15min)
faculty TBD (pharmacy, medicine, nursing, PA)
SAME AS ABOVE
11:20–11:30AM Transition back to big group
11:30 AM–12:00PM Wrap up Goals: 1. Reflections of students2. Descriptions of roles3. Debrief as large group
Faculty to lead big debrief
Whiteboard
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FacultyRequirements
AllfacultyshouldbefamiliarwiththebasicsofTeamSTEPPS.Anarratedslidesetisavailableforreviewonthecollaborate.uw.eduwebsiteandaglossaryoftermsisincluded.LinktoTeamSTEPPSmodule.
FacultynewtosimulationcanalsoreviewanonlinemoduleIntroductiontoClinicalSimulation.
Facultyshouldalsobefamiliarwiththemanagementoftheclinicalproblemspresentedbythesimulationscenariotheywillfacilitate.Thesearefairlystraightforward,andthefacultyguideforeachscenarioincludesbackgroundinformationandcommonissuesthatarise.
CourseName/DesignGroupInfo
DevelopmentTeam: Brenda Zierler, Brian Ross, Karen McDonough, Sara Kim, LindaVorvick,PeggyOdegard,SarahShannon,SharonWilson
IntendedAudience: 4th Year Medical Students, 4th Year Nursing Students, 4th YearPharmacyStudents,2ndYearPhysicianAssistantStudents
Participants: EachModulerequires:• 2medicalstudentsplayingrolesofresidents• Aphysicianassistantplayingtheroleofamedicalprovideron
theteam• Anursingstudentplayingtheroleofabedsidenurse• Anursingstudentplayingtheroleofafloornurseavailableto
giveassistance• Apharmacystudentplayingtheroleofaninpatientpharmacist
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Debriefing
LETTHETRAINEESDOMOSTOFTHETALKINGYoushouldjustbeafacilitator.Letthembringuptheissuestheyfeelneedtobediscussedandyoufinishbyfillinginwhatwasnotdiscussed.
STARTwithaClinicalDebriefStartbyaddressingclinicalmistakesorotherclinicalissuestheteambringsup.Studentswillnotbeabletofocusoncommunicationskillsiftheyhavemajorclinicalquestionsorconcerns.However,donotspendmuchtimeonthis(<5min).Scenario‐specificdebriefingtipsareincludedwitheachscenario.
SPENDTHEMAJORITYOFTHETIMEonTeamSTEPPSDebrief
Startbyaskingopenendedquestions.Asparticipantsrespond,rephrasetheirresponsesbacktothemasTeamSTEPPSskillsthatwillbecoveredinthatmodule.Ifoneoftheskillsisnotbroughtupbythegroup,youcanbringitupbrieflyatthecloseofthedebrief.
Howdiditgo?Rememberthetraineeswillbehardonthemselvessoencouragethemtofocusinitiallyonwhat
theydidwell.Mostofthefeedbacktraineesreceivethroughouttheirtrainingisnegative,sothewholetenorofthedebriefcanbeaffectedandimprovedbystartingwithpositivefeedback.
Whatdidyoudowell? Don’tletthemgotowhattheydidbadly,butwhattheydidwellfirst
Whatcouldyoudobetter? Thisquestionwilloftengetyouoffthehookfortellingthemwhattheydidbadly.Whenyouaskthisquestionthetraineeswillinvariablybringupthosemanagementareasthatyouweregoingtomention.
Whatwillyoudodifferentlynexttime? Thiswillhelpthetraineesfocusonreallymakingmeaningfulbutsimplechangesforthenexttime.
FinishbypromptingthemaboutanyspecificTeamSTEPPSskillsthatdidnotcomeoutwithopenendedquestions.(seebelow)
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Theexamplesbelow*allowthefacilitatortodrawoutfromtheteamthebehaviorswhichtheythemselvesexhibitedandobserved.Thebehaviorsontheleftsideofthematrixarepositive,andtheonesontherightarenegative.Usuallytheteammembersareabletoseewhattheydidanddecideifitwas“good”or“bad”.
Element Positive Negative
EstablishtheTeam Relaxed,supportiveandapproachable
Createsatmosphereforopencommunication
Encouragesinput/feedbackfromothers
Doesnotcompetewithothers
Politeandfriendly
Appropriateuseofhumor
Tense,unapproachableandawkwardtorelateto
Blocksopencommunication
Ignoresbarriersbetweenteammembers
Competeswithother
Rudeanddismissive
Inappropriateuseofhumor
ClosedLoopCommunication Usesname,eyecontact,orpointingwhenmakingrequest
Repeatstherequest
Reportsbacktotheteamleaderwhenrequestiscompleted
Makesarequestwithoutdirectingtowardsaspecificteammember
Ignorestorepeattherequest
Failstoreportbacktotheteamleaderregardingthestatusoftherequest
*AdaptedfromTeamSTEPPSandBritishAirwaysCheck‐flightDebriefTool
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TeamSTEPPSDebrief#1–100LevelSkills
1. Discuss the concepts of:A. Conducting a DebriefB. Leadership
• making requests• expecting cross-checks• task prioritization• workload balance
2. Discuss Communications SkillsA. RequestB. Cross-checkC. Check-backD. Call OutE. SBAR
TeamSTEPPS Debrief:
Ask: HowdidyoudoatincorporatingtheTeamSTEPPScommunicationskillsintoyourmanagementofthispatient?
1. Did you know who your leader was?• Someone assuming the leadership role — Point out how when someone assumed a leadership role it helped the
team plan for the times when team members were no longer able to communicate verbally. If none of thegroups had a member who did this, point out how this would have helped.
2. Did you have clearly defined team roles?• Clearly defined team roles — Ask if any of the teams had designated people who agreed to take on certain
roles. Ask if anyone was standing around wondering what to do because a clearly defined role was lacking.
3. Task Prioritization• Did the tasks get done in the correct order with emphasis on the most important first?• Did the tasks get reassigned if someone was assigned and was unable to complete the task?
4. Communication – Please discuss these specific communication skills:
Making a Request• Look at the person you are making the request to, point at the person you are making the request to
Cross-checks • Process of expecting and demanding ‘parroting’ of requests:
1. Sender initiates the message2. Receiver accepts the message and provides feedback3. Sender double-checks to ensure that the message was received
Check-backs • Process of employing closed-looped communication to ensure that information conveyed by the sender is
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understood by the receiver as intended
• Checking back with the leader when the task is completed or their inability to complete the task
• Did you have the opportunity to practice closed-loop communication?
Call-Outs • Strategy used to communicate important or critical information
o informs all team members simultaneously during emergent situationso helps team members anticipate next stepso important to direct responsibility to a specific individual responsible for carrying out the task
• Reporting to the leader or team unrequested information• Reporting to the leader or team important information that was requested
SBAR: Situation, Background, Assessment, Recommendation • Often it might be better to start with the recommendation, then B, then A, then repeat R
Situation: What is going on with the patient? Background: What is the clinical background or context? Assessment: What I think the problem is? Recommendation and Request: What would I do to correct it?
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TeamSTEPPSDebrief#2–200LevelSkills
1. Discuss the concepts of:A. Situational Awareness
2. Discuss Communications SkillsA. BriefsB. DebriefsC. HuddlesD. HandoffsE. SBAR
TeamSTEPPS Debrief:
As participants respond, rephrase their responses back to them as TeamSTEPPS skills. If one of the skills is not brought up after each group responds, you can bring it up later.
Ask: HowdidyoudoatincorporatingtheTeamSTEPPScommunicationskillsintoyourmanagementofthispatient?
1.Situational Awareness — the state of knowing the current conditions affecting the team's work• Knowing the status of a particular event• Knowing the status of the team's patients• Understanding the operational issues affecting the team• Maintaining mindfulness
Conditions that Undermine Situation Awareness (SA): Failure to- a) Share information with the team b) Request information from othersc) Direct information to specific team membersd) Include patient or family in communicatione) Utilize resources fully (e.g., status board, automation)
Process of actively scanning behaviors and actions to assess elements of the situation or environment a) Fosters mutual respect and team accountabilityb) Provides safety net for team and patientc) Includes cross monitoringd) Remember, engage the patient whenever possible.
3. Team Skills
Brief• Short session (this is not a LONG) prior to the start of – the day, a clinic, a procedure, etc – to discuss
team formation; assign essential roles; establish expectations and climate; anticipate outcomes and likelycontingencies
• Should address the following questions:
Who is on the team? All members understand and agree upon the goals?
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Roles and responsibilities are understood? What is our plan of care? Staff and provider’s availability throughout the shift? Workload among team members – balance and prioritized? Availability of resources?
Debrief • Informal information exchange session designed to improve team performance and effectiveness; after
action review; should follow the plan:
“What did you do or what went well”, “What could you have done better?” End with: “What should we do differently next time?”
• Should address the following questions:
Communication clear? Roles and responsibilities understood? Situation awareness maintained? Workload distribution equitable? Task assistance requested or offered? Were errors made or avoided? Availability of resources?
Huddle • Ad hoc planning, often around a single patient or event to establish or reestablish situational awareness;
reinforcing plans already in place; and assess the need to adjust the plan. Huddles can frequently happen several times during a critical event.
Hand-Off • The transfer of information (along with authority and responsibility) during transitions in care across the
continuum; to include an opportunity to ask questions, clarify, and confirm. Examples:
Shift changes Physicians transferring complete responsibility Patient transfers
SBAR: Situation, Background, Assessment, Recommendation • Often it might be better to start with the recommendation, then B, then A, then repeat R
Situation: What is going on with the patient? Background: What is the clinical background or context? Assessment: What I think the problem is? Recommendation and Request: What would I do to correct it?
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TeamSTEPPS/TeamSkillsDebrief#3–300LevelSkills
Discuss the concepts of:A. Mutual support
Discuss Communications SkillsA. CUSB. 2-Challenge RuleC. DESC
TeamSTEPPS Debrief:
As participants respond, rephrase their responses back to them as TeamSTEPPS skills that will be covered in the training. If one of the skills is not brought up after each group responds, bring up that skill briefly afterward.
Ask: HowdidyoudoatincorporatingtheTeamSTEPPScommunicationskillsintoyourmanagementofthispatient?
4. Mutual Support —• Is the essence of teamwork• Protects team members from work overload situations that may reduce effectiveness and increase the
risk of error CUS: I am Concerned!
I am Uncomfortable! This is a Safety Issue
2 Challenge Rule: • Empower any member of the team to "stop the line" if he or she senses or discovers an essential safety
breach. • This is an action never to be taken lightly, but it requires immediate cessation of the process and
resolution.
When an initial assertion is ignored… it is your responsibility to assertively voice concern at least two times to ensure it has been
heard the team member being challenged must acknowledge if the outcome is still not acceptable: take a stronger course of action and utilize supervisor or
chain of command
DESC-It (Describe, Express, Suggest, Consequences) • A constructive approach for managing and resolving conflict
D Describe the specific situation or behavior; provide concrete dataE Express how the situation makes you feel/what your concerns areS Suggest other alternatives and seek agreementC Consequences should be stated in terms of impact on established team goals; strive for consensus
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TeamSTEPPSGlossary
Concept DefinitionBrief Shortplanningsessionpriortostarttodiscussteamformation;assignessential
roles;establishexpectationsandclimate;anticipateoutcomesandlikelycontingencies.
Huddle Adhocproblemsolvingplanningtoreestablishsituationawareness;reinforcingplansalreadyinplace;andassessingtheneedtoadjusttheplan.
Debrief: Informalinformationexchangesessiondesignedtoimproveteamperformanceandeffectiveness;afteractionreview.
StepProcess:
Atoolformonitoringsituationsinthedeliveryofhealthcare.ComponentsofSTEPsituationmonitoringinclude:
1) Statusofthepatient(S):patienthistory,vitalsigns,medications,physicalexam,planofcare,psychosocial2) Teammembers(T):fatigue,workload,taskperformance,skill,stress3) Environment(E):facilityinformation,administrativeinformation,humanresources,triageacuity,equipment4) Progresstowardgoal(P):statusofteam’spatients,establishedgoalsofteam,tasks/actionsofteam,planstillappropriate.
Two‐ChallengeRule:
Whenaninitialassertionisignoreditisyourresponsibilitytoassertivelyvoicetheconcernatleasttwotimestoensureithasbeenheard.Theteammemberbeingchallengedmustacknowledge.Ifoutcomeisstillnotacceptable,takeastrongercourseofactionorusechainofcommand.
CUS: Statementof:IamConcerned,IamUncomfortable,ThisisaSafetyIssue!
DESCScript: Approachtomanagingandresolvingconflict.1) Describethespecificsituationorbehavior;provideconcretedata2) Expresshowthesituationmakesyoufeel/whatyourconcernsare3) Suggestotheralternativesandseekagreement4) Consequencesshouldbestatedintermsofimpactonestablishedteamgoals;striveforconsensus
SBAR: Techniqueforcommunicatingcriticalinformationthatrequiresimmediateattentionandactionconcerningapatient’scondition:1)Situation(whatisgoingonwiththepatient?),2)Background(whatistheclinicalbackgroundorcontext?),3)Assessment(whatdoyouthinktheproblemis?),4)RecommendationandRequest(whatwouldIdotocorrectit?).
Call‐Out: Strategyusedtocommunicateimportantorcriticalinformation.E.g.TeamLeaderCallsout=“Airwaystatus?”,AssessingClinicianResponse=“Airwaystatusclear”
CheckBack: Processofemployingclosed‐loopcommunicationtoensurethatinformationconveyedbythesenderisunderstoodbythereceiverasintended.E.g.Teamleader“Give25mgBenadrylIVpush”,Clinician:“25mgBenadrylIVpush”,TeamLeader“That’scorrect”
Hand‐OffTechniques:
Transferofinformation(alongwithauthorityandresponsibility)duringtransitionsincareacrossthecontinuum;toincludeanopportunitytoaskquestions,clarify,andconfirm.
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ClinicalScenario:DyspneainaHospitalizedPatientOverview
Phil Brown is a 72 year old man who passed bright red blood with a bowel movement 12 hours ago. After several more episodes, he came into the Emergency Dept. He was hemodynamically stable, and hematocrit was 24 about 10 hours ago. No active bleeding was seen with anoscopy at that time. He was admitted to the medical floor received IV fluids and 2 units of red cells, and is being prepared for a colonoscopy tomorrow. It is 2300 shift change. The primary medical team has signed out to the cross cover team, and the nurses have just changed shifts. Phil, played by a patient actor, awakes acutely short of breath.
The scenario begins with the handoff from Phil’s evening shift nurse(s), played by a faculty member, to the night nurse, played by a nursing student. The student nurse will have the opportunity to clarify and summarize the handoff communication.
When the night nurse(s) assesses Phil, he finds the patient to be acutely dyspneic. After a rapid assessment, the nurse should call the cross-cover intern or PA, communicate his concern, findings, and assessment, and make a recommendation that the patient be evaluated immediately. The cross-cover intern or PA, who has been sitting in the ‘team room’ with the other resident(s) and pharmacist should inform the rest of the team of the situation and report to the patient’s room.
The team then evaluates and manages Phil’s dyspnea. On his initial exam, he has loud crackles and difficult to hear heart sounds. A chest x-ray (if requested) is consistent with pulmonary edema. An ECG shows tachycardia. Routine labs show improvement of anemia post-transfusion, and a blood gas shows hypoxia.
If Phil receives diuretics, his symptoms quickly improve. His lungs clear, and an aortic stenosis murmur becomes easily audible if he is re-examined. The examiner has the opportunity to ‘callout’ the new finding, and the team can then revise their shared mental model.
Unbeknownst to the cross cover team, Phil had a loud murmur on admission. This was not signed out to the cross cover intern. He has unrecognized calcific aortic stenosis (which will be audible to the student using a Ventriloscope) and has developed CHF in the setting of excess volume administration.
The scenario then cuts to 7 am, when the primary intern (played by faculty) arrives back at the hospital, and the cross-cover intern or PA hands off Phil’s care and scenario ends.
Thefocusofthescenarioshouldbeonthecommunicationbetweenteammembers,notthemedicalmanagement.
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Timeline
5minutes Briefreviewofthedifferentialdiagnosisandinitialworkupofdyspneainahospitalizedpatient.Thisclinicalreviewshouldallaystudentanxietyaboutclinicalmanagement,andallowthemtofocusmoreonteamcommunication.
5minutes IntroductiontotheVentriloscopeandthesimulationsetting
15minutes Runscenario
Act1,Scene1: Handofffromeveningtonightnurse(s)andinitialassessment
Act2: TeamevaluatesandmanagesPhil’sdyspnea
Act3: Philimprovesfollowingdiuretics,andanASmurmurbecomesaudible
Act4: Thecross‐coverinternorPAhandsPhil’scarebacktotheprimaryIntern
15minutes Debrief
ScenarioParticipants
Medical and/or PA students (maximum 3)A. Interncross‐coveringthepatientorPAreceivesthe‘sign‐outsheet’B. Seniorresident(s)
Nursing students (work as a team; maximum 2) A. PrimarynightnurseB. Asecondfloornurse
Pharmacy student(s) (work as a team; maximum 2) A. Medicalfloorpharmacist
Studentobservers(remainingstudentsnotassignedarole)
1Nursingfaculty–provideshandofftotheprimarynightnursetostartthescenario.Ifthingsarenotflowingsmoothly,couldalso“comebacktohelpout”.
1Medicinefaculty–actsastheprimaryintern,whoreceivessignoutfromthecross‐coverteamthefollowingmorningtoendscenariorealistically.
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ClinicalOverview
Onefacultymembershouldbrieflydiscussthedifferentialdiagnosis,initialevaluation,andinitialmanagementofacutedyspneainthehospital.Thisshouldbeinteractive,andtake<5minutes.Youdonotneedtocoveralltheinformationbelow–itisincludedasarefresher.
Exampleoutline:“Acuteshortnessofbreathisacommonprobleminhospitalizedpatients,andit’stheproblemyou’llbeassessingandmanaginginthisscenario.Sayyourpatientiscomplainingofdyspnea–whatisyourinitialdifferentialdiagnosis,beforeyouhaveanyadditionalinformation?”
MajorcausesofdyspneainthehospitalCardiac
VolumeoverloadIschemiaArrhythmiaTamponade
Pulmonary:Parenchymal(AbnormalCXR)HealthcareassociatedpneumoniaAspirationARDS/AcuteLungInjuryTransfusionrelatedALIPneumothorax
Pulmonary:Airflow(OftennormalCXR)AsthmaCOPDAnaphylaxis/hypersensitivityUpperairwayobstruction(angioedema)Lowerairwaysobstruction(mucousplugging)
PulmonaryVascular(NormalCXR)PulmonaryEmbolismAirembolism
MetabolicSepsisAcidosisAnemia
“Whatwillyourinitialevaluationconsistof?”1. Focusedhistory&physical2. Reviewrecenttreatmentandprocedures3. Chestradiograph4. ECG5. Bloodgas6. Labs:Troponin,BNP,CBC,Chem,Coagindices7. ConsideradvancedimagingforPE/DVT
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“Obstructivelungdisease,pulmonaryedema,healthcareassociatedpneumonia,anxiety,andpulmonaryembolismarethemostcommonreasonsforacutedyspneainthehospital.Whatwouldyourfirststepsintreatmentbeforeachofthese?”
Obstructiveairwaysdisease:Bronchodilators,steroidsNon‐invasivebi‐levelpositivepressureventilation:GoodforCOPD,lesshelpfulforasthma
CardiogenicPulmonaryEdema:TreatunderlyingischemiaorrhythmLMNOP:Lasix,Morphine,Nitrates,Oxygen,Pressure(Bi‐PAP)
HealthCareAssociatedPneumoniaBroadspectrumantibioticstocoverresistantGNRandGPCNarrowantibioticsbasedonsputumGSandculturelater
PulmonaryembolismIfhighsuspicionofPE,lowriskofbleeding.Canstartanti‐coagulationpriortodefinitiveimagingNon‐massivePE:Un‐fractionatedheparin(UFH)orLMWHMassivePE:ICUEvaluation,UFH,considertPA
AnxietyReassurancePharmacologictherapyshouldprobablybewithhelduntilotherdiagnosesexcludedwithreasonablecertainty
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IntroductiontoSimulator
Onefacultymembershouldintroducethestudentstothesimulationscenarioandequipment,insomedetail.
Thisintroductionshouldcover:
A Overviewofscenario:“Inthisscenario,you’llbecaringforPhilBrown,a72yearoldmanadmittedearliertodaywithaGIbleed,whoisnowacutelyshortofbreath.Philisonamedicalfloor,inastandardhospitalroom,gettingpreppedforacolonoscopyinthemorning.Itisaboutmidnight,shortlyafterchangeofshiftforthenurses.Themedicalteamisthecross‐coverteam,whogotsign‐outonMr.Brown3hoursago.”
B Overviewofequipment“Philisapatient‐actor,inastandardhospitalbedandamonitorcapableofdisplayingsimulatedvitalsandtelemetry.Thisistheautomatedbloodpressurecuffconnectedtothemonitor.Youwillneedtocalloutarequestforcontinuousmonitoring.IfyouplacePhilontelemetry,O2Satand/orautomaticbloodpressuremonitoring,hisresultswillautomaticallydisplay.”
“Philshouldbeexaminedusingthisspecialstethoscope,calledaventriloscope.Itplaystheexamfindingswewouldlikeyoutohearandincorporateintoyourdiagnosticthinking.Besureyouhearthefindingsoraskifnoneheard.Ourpatient‐actor’sphysicalexamisactuallynormal,butwiththisventriloscopeyoumaydetectabnormalfindings.”
“Usethetelephone(orpretendtouse)tocallthemedicalteamroomtocomestattoevaluatepatient.”
“PhilhasanIVyoucaninjectmedicationsanddraw‘blood’from.Medicationsarelocatedonthispharmacycart.Syringesandphlebotomysupplieswithoutneedles,andbloodtubesarehere.Ifyouareaskedtodrawbloodoradministermeds,usethisIV.”
“Respiratoryequipment,includingnasalcannulaandanon‐rebreathermaskareattheheadofthebed.”
C Diagnostictestingandresults“Philhadrepeatlabsdrawnjustbeforethescenariostartandthenightnursehastheresults.Youcancallthelabforaddonlabs.Ifyouwantabloodgas,youshouldgothroughthemotionsofobtainingonewithoutaneedleontheABGsyringe.Resultswillbecalledoutwhenavailable.IfyouwantanECG,askforonetobedone.YouwillbehandedaprintoutoftheECG.Ifyouwantachestx‐ray,requestone.Youwillbenotifiedwhenthefilmisavailable– itwillbebroughttoyou.”
D Otheravailabledata“TheadmitH&Pisonthechartandavailablefromthenightnurse.ThecrosscoverinternorPAwillhaveasign‐outsheetincludinginformationonPhilBrown.Thenightnursewillreceiveahandoffsheetandcurrentlabresultsfromtheeveningnurse.”
E Medicationsandadministration
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“Immediatelyavailablemedicationsarehereonthispharmacycart. Youwillneedtocallthepharmacyforotherrequests.IfyouneedtoadministeramedicationIV,usethisIV.Ifitisanoralmedication,itisokaytoadministeritorallytoPhil.”
F Glovesandhand‐gelareavailable
G Questions?
H Introducetheparticipants:“Wewillhavestudentsparticipateinthefollowingroles:
____medicinefloorinternorPAcrosscoveringthepatient.____seniorresident(R3).____nightshiftnurse(s).____hospitalpharmacist.____non‐participatingstudentswillbeobserversandaskedtoparticipateindebrief
Facultyalsohaveroles:___,oneofournursingfaculty,willplaytheeveningnursegivingreportonthepatient___,oneofthePAfaculty,willbetheprimaryinterngivingsign‐outsheettomedicalteamandreceivingreportaboutthepatientinthemorningtoendscenario___,allfacultywillstepintoscenariotoassistwithmedicalcontenteitherbyrequestorifneededtoguidescenariotocompletion”
I Startingthescenario:“Themedicalteam,alongwiththenightpharmacistareintheteamroom‘acrossthehall’,wheretheycanbecalledifneeded.Youmaysay:‘Medicalteam,whydon’tyouheadacrossthehallandwewillstart.’Oncethemedicalteamisoutofear‐shot,theywillbegiventhesign‐outsheet(crosscover)androlesdelineatedbythemedicalandpharmacyfaculty.ThescenariowillstartoutsideofPhil’sroom,withtheeveningnurse(faculty)handinghiscareofftothenightnurse(s).”
J Endingthescenario:At7am,primaryintern(playedbyPAfaculty)arrivesbacktoreceivereportaboutPhil’scarefromthecross‐coverinternorPA.
K Remember:TimeTimeiscompressedoverashift—Midnightto0700.
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DebriefingTips
(seeTeamSTEPPSdebriefforteamcommunicationobjectives)
WhatdidyouthinkwasgoingonwithPhil?Whatsupportsthis?Whatelsewereyouconsidering?
Phildevelopspulmonaryedemaduetovolumeoverloadsecondarytoisotonicfluid,blood,andtheFleet’sprephereceived.HealsohasunrecognizedaorticstenosiswhichwasnotedonhisadmitH&Pbutnotreportedtocross‐coverteam.
Thecracklesonexamsupportthisdiagnosis,asdoeshischestx‐rayandhisresponsetolasix.Hismurmurbecomeseasiertohearashiscracklesclear,alsosupportingthediagnosisofvalvularheartdisease.
Cardiacischemiaislesslikely,givenhislackofchestpainorpressure,lackofECGchangesofischemia,andeventually,hisnormaltroponin.
Anemiafromrecurrentbleedingisareasonableconsideration,butlesslikelygivenlabresultsandthefindingsofcracklesandedemaonCXR.
Pulmonaryembolismisunlikelygivenhisveryrecenthospitalizationandx‐rayfindings,andobstructivelungdiseaseisunlikelygivennohistoryofsmokingorsimilarsymptoms,andnowheezing.
Howdidyourevaluationandmanagementgo?Commonmanagementproblemsinclude:
a. Diureticdosing.Ofcourse,thereisnosinglerightanswerhere,but5mgofIVlasixisprobablynotenoughforsomeoneinPhil’ssituation,and160mgisprobablytoomuchforsomeonewhoisdiuretic‐naïve.
b. ThinkingPhilisinworseshapethanheactuallyis(i.e.callingforanesthesiawhenheison4litersofoxygen.)Thistendstobeparticularlytruewhenthestudentshavejustperformedasimulationinvolvingaresuscitationorintubation.“Whenyoucomefromacode,youthinkthenextthingisgoingtobeacode,too.”
c. Teammayfixateoncardiacischemiaasacauseofhissymptoms.Facultymentorswillneedtoredirecttheteamifthishappens.Mayaskteamto“huddle”toredirect.
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MedicalTeamHandoffSheet
(forcross‐coverinternApocket)
Patient Problemlist Medications Plan
Brown,PhilU1122334
6NE,room6214
1. ProbablelowerGIbleed,seemstohavestopped
2. Anemia,receiving2ndof2unitsPRBC
3. RepeatHctorderedat2200afterlastunitinfused
Fleet’sprepPantoprazoleAcetaminophenprn
CheckHctresultsorderedat2200–if<25,reevaluate,repeatin4hoursandconsidertransfusionCheckat0600tobesurestoolhascleared–colonoscopyplannedforAM
Wells,CarolynU9872341
6SE,room6110
1. CAP,improving2. Hypertension3. Multiplesclerosis4. Hypokalemia,withKof3.0
today
LevofloxacinLisinoprilPrazosinHCTZBeta‐interferonKCl120meqPOtoday
CheckChem7at2000–repleteKifneeded
Mitchell,StephenU7680989
6NE,room6252
DNR
1. Hepatorenalsyndrome2. Cirrhosis3. Hepaticencephalopathy4. Transplantevaluation
MidodrineOctreotideLactuloseRifaximinNadololOxycodoneprn
Doingpoorly,familyconsideringcomfortcare.Ifgettingworse(moreconfused,GIbleeding,etc)callattendingtodiscuss.
Jones,JoshU4432567
6NE,room6264
1. Cysticfibrosisexacerbation
2. Newdiagnosisofdiabetes,likelyduetopancreaticinsufficiency
Piperacillin‐tazoTMP‐SMXInhaledtobramycinInhaledDNAaseAlbuterolprnVitaminsADEKPremealinsulinlispro
Pulmonarystatusisimproving–pleaseFUonanyrecsfromPulmonaryconsultteam
Checkpre‐dinnerbloodsugarIf>180startinsulinglargine10unitsSCqhs
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NursingHandoffSheet
(for11‐7RNpocket)
Patient Problemlist Medications PlanBrown,PhilU1122334
6NE,room6214
1. ProbablelowerGIbleed,seemstohavestopped
2. Anemia,receiving2ndof2unitsPRBC@1900
3. RepeatHctorderedat2200afterlastunitinfused
4. Colonoscopyprepcompleted
5. NPO6. Foleycathinplace–
output50cceveningshift
Fleet’sprep@2000
Pantoprazole40mgIVPgiven@1600
Acetaminophenprn–nonegiven
IVLR1liter@150mL/hr–2bagseveningshift
AdministerbowelprepasorderedAssisttobathroomprnBMCheckat0600tobesurestoolhasclearedcolonoscopyplannedforAMHct30post‐[email protected]‐coveringmedicalteam.
Wells,CarolynU9872341
6SE,room6110
1. CAP,improving2. Hypertension3. Multiplesclerosis4. Hypokalemia,withKof
3.0today
LevofloxacinLisinoprilPrazosinHCTZ
Chem7resultsonchartby2000–basedonresults,mayneedrepleteK.Administermedsasordered.
Mitchell,StephenU7680989
6NE,room6252
DNR
1. Hepatorenalsyndrome2. Cirrhosis3. Hepaticencephalopathy4. Transplantevaluation
MidodrineOctreotideLactuloseRifaximinNadololOxycodoneprn
Doingpoorly,familyconsideringcomfortcare.Providesupportivecareforpatientandfamily.Administermedsasordered.
Jones,JoshU4432567
6NE,room6264
1. Cysticfibrosisexacerbation
2. Newdiagnosisofdiabetes,likelyduetopancreaticinsufficiency
Piperacillin‐tazoTMP‐SMXInhaledtobramycinInhaledDNAaseAlbuterolprnVitaminsADEKPremealinsulinlispro
Arrangefordiabeteseducatortoseept/family.Bloodglucosebeforedinner.If>180startinsulinglargine10unitsSCqhsOrderlowfat,nosugardiet,caloriesperdiabeticeducatorrecommendations.
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PhilBrown:AdmitHistoryandPhysical
(fordesktopcomputerorhardbackchart)
Mr.Brownisa72y.o.manwith4hoursofBRBPR(brightredbleedingperrectum).Hewokethismorningwiththeurgetodefecate,rushedtothebathroom,andpassedalargeamountofblood.Hehad4or5morebloodybowelmovementsoverthenext2hoursbeforecomingintotheED.Atthetimeofinitialevaluation,hehadhadnobloodforoveranhour.HisbloodpressurewasnormalandhisfirstHctwas28.AnoscopyintheEDwasnegativeforblood,andNGaspirateshowedbiliousfluid.After2litersofIVfluidinED,hisHctwas24.Chestx‐raynormalinED.Hewasadmittedtothemedicalfloorforfurtherevaluation.
Mr.Bdeniesabdominalpain,nausea,vomiting,chestpain,andlightheadedness.Hehadnoloosestoolsbeforetoday.HehasnopriorhistoryofGIbleedingorliverdisease.Hedenieshemorrhoids.HehasneverhadacolonoscopyorEGD.Heisnotanticoagulated,butdoesreportNSAIDuse3or4xperweek.Nofevers,chills,changeinappetiteorweightloss.Norecenttravel.Drinkscitywater,deniesunusualfood,unpasteurizedmilkorcheese,animalexposure.
PMH: Kneesurgeryin1972Pneumoniain1991
Medications: NKDAOccasionalibuprofenorASA,nomorethan4times/week
Socialhistory: Liveswithhiswife,Eileen. Retiredaccountant. LikesMariners,gardening.Nonsmoker,minimalalcohol.
ROS: Negative
Physicalexamination: VS:HR96 BP 144/66 RR16 Temp:37oC O2sat95%onRAHEENT:+conjunctivalpallor;normaloropharynxHeart:RRR,2‐3/6systolicmurmurloudestattheRUSB,possibleradiationtocarotid.NoS3orS4Lungs:clearAbdomen:normoactiveBT,soft,nontender.NoHSM.Rectalexam
normal,nostoolinvault,anoscopynegativeperED.Extremities:LEedema1+EDLab: Electrolytesnormalrange
CBCwithHgb8,Hct24,MCV91,platelets136,WBC8Stoolforentericpathogens,C.diffpendingIronstudiespending
EDChestxray:normal
Assessment: 1. OnedayhistoryofBRPBR,whichhasnowstopped.HeishemodynamicallystablebutHctis24,necessitatingadmissionfortransfusionandfurtherevaluation.Giventheacuityandseverity,themostlikelycauseofbleedingisdiverticularhemorrhage.OtherpossibilitiesareAVMsandulcers.Infectionisunlikelygiven
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lackoffever,leukocytosisandexposure. Coloncancerisapossibility.
2. Heartmurmur,nopriorevaluation
Plan: 1. BRBPRa. LargeboreIVb. T&Cfor4units,transfuse2unitsPRBCsandrepeatHct;if
>28repeatinamORifclinicalevidenceofbleedingc. Colonoscopytomorrow–Fleetspreptonightd. Pantoprazole40mgIVqd(incaseUGIsource)
2. Heartmurmura. Outpatientecho
3. Fluids,electrolytesandnutritiona. LR150cc/hourb. NPOforcolonoscopyprepc. Foleycatheteruponadmission
4. Prophylaxisa. DVT–ambulatoryb. BRprivilegeswithassistance
5. Codestatus‐full
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PhilBrown:InformationforActorPortrayingPhil
Initialresponsetoanyopenendedquestion(deliveredinabreathlessway):
I’mreallyshortofbreath. IwasfeelingprettygoodbeforeIwenttosleepat0930butwhenIwokeupat2330Icouldbarelymakeittothebathroom.Isatonthesideofthebedforawhilebutitjustkeepsgettingworse.
Anyothersymptoms? NO
Whatmakesitbetter? Nothing
Whatmakesitworse? Doinganything
Anythinglikethishappenbefore?
Nochestpainorchestpressure orshortnessofbreathbefore.
Whatdoyouthinkisgoingon?
Imustbehavingabadreactiontothebloodormedicationstheygaveme.
Ifaskedspecifically,youDO:
Haveageneralsenseoffatigue
Ifaskedspecifically,YOUDONOTHAVE:
Anymorebloodybowelmovements. Lastonewasat10am.Anyhistoryofheartproblemsorheartmurmur(butyoudon’tseeadoctormuch)Chestpain,tightnessorpressurewithexertionoratrestFaintingPalpitationsorasensethatyourheartisflutteringPreviouswakingupatnightfeelingshortofbreathCoughWheezingCoughingupbloodUnexplainedweightgain
Ifaskedspecifically,youalsodonothave:
SleepapneaAnyhistoryofbloodclotsordeepveinthrombosisAnyhistoryofanemiaAnyTBexposureortraveloutsideofWashingtonStateHeartburnorrefluxFeverorchillsWeightlossSwollenlymphnodesDiabetes,hypertension,orelevatedcholesterol(thatyouknowabout–youdon’tseeadoctormuch)
PersonalHistory IwasbornandraisedinSeattle,andgraduatedfromtheUW. I’vebeenmarriedfor36years,andIhave3grownchildrenand2
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grandchildren. Theyalllivearoundhere,andIlovespendingtimewiththekids.
Iretiredfromaccounting5yearsago.IenjoytheMarinersandgardening.
Habits IwaswalkingaroundGreenLakeeveryday.
Idon’tsmoke,althoughIdidforafewyearsinmytwenties.Ihaveabeerortwoonweekends.Idon’tuseanycaffeine.
SexualHistory I’vebeenmarriedtomy wife,Eileenfor36years.Nootherpartners.
FamilyHistory Mymomdiedat65ofcongestiveheartfailure.Mydadis94andprettyhealthy,justgettingoninyears.Ihave3kids–theoldesthashighbloodpressuretoo,buttheothertwoarehealthy.
PastMedicalHistory I’mreallyprettyhealthy,don’tseeadoctormuch.I’vehadsomekneepainandhavetakensomeaspirinoribuprofenbutnotmuchelsewrongwithme.
Medications: Aspirinoribuprofenacoupleoftimesaweekforkneepain. Theotherdoctorsthoughtthatmighthavebroughtonthebleeding.
Allergies: none
HealthInsurance: Medicare
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SimulationScenarioRequirementsandEquipment
Simulator: Patient‐actorw/ventriloscope– orhighfidelitymanikinwithlungandheartsoundtechnology
Dressedinahospitalgownandpajamabottoms,withasimulatedurinarycatheterandperipheralIV,sittingupinbedandactingshortofbreath.
Lecat’sVentriloscope(orinplaceof,highfidelitymanikinwithlungandheartsoundtechnology)MonitoravailableifrequestedtodisplaycontinuouslyBP,rhythmstripandO2Sat.
SETTING Standardhospitalequipment:Hospitalbedwithpillow,sheets,andblanketBed‐sidetableBloodpressurecuffandventriloscopestethoscopeorstethoscopeifmanikinPatientIDbandECGelectrodesHandgelExamgloves
Operational(orpretendequivalent)telephonewithpostedphonenumbersfor:
Medicalteamroom (nightnursewillcallcross‐coverinternatthis#)Lab(anyteammembercancallforresultsortoaddlabs.Mustbemanned)
Desktopcomputerwithmonitorandon‐screeniconsorprintedchartcopiesof:
History&PhysicalEDLabsEDCXR
Respiratoryequipment NasalcannulaNon‐rebreathermaskOxygenFlowmeterPulseoximeterfingerprobe
Urinarycatheterequipment FoleycatheterCollectiontubingandbagIVbagfilledwithsimulatedurine(yellowwater),connectedtocollectiontubingforreleaseofurineintourinebagifgivenLasixtosimulatediuresis
IVequipment IVpoleIVinfusionline(Y‐administrationsetforbloodinfusion)withdrainageforIVpushmedsIVbagLactatedRingersX2bagsInfusedbloodbag
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Medicationsandequipment: Lasix20mg/mL 1vialclearlylabeledMorphine 1vial(1mg/ml)Nitroglycerinepaste tubeofhandcreamrelabeledDiphenhydramine25mgtabs TicTac’sAspirin325mg TicTac’sSyringeswithoutneedles 3mlX5;5mlX5;10mlX5Alcoholwipes Formedsandblooddraw
Labdrawequipment ABGkitsx3VenipuncturesetBloodtubes–purpletop,redtop
Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:
Bloodgases– hypoxiabutnotdeteriorating,repeatvaluesunchangedCBC–Hct30,Hgb12forRNsign‐outsheet,Hct33,Hgb13foradditionalrequestsElectrolytes–normalvaluesandstableBUN,Creatinine‐normalvaluesandstableGlucose‐normalvaluesandstableUA‐normalvaluesandstableCardiacenzymes‐negativeandstableBNP–550ng/L(elevated)EDChestx‐ray–negativeRepeatchestx‐ray–pulmonaryedemaandcardiomegalyECG–tachycardiaonly(noischemicchanges)Anticoagulantstudies‐normalvaluesandstableAcuteLabprintout:CBC,Chem7,Cardiacenzymes,BNP(high)
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Storyboard
PhilBrownisa72yearoldmanwhopassedbrightredbloodwithabowelmovement12hoursago.Afterseveralmoreepisodes,hecameintotheEmergencyRoom.Hewashemodynamicallystable,andhematocritwas24about10hoursago.Noactivebleedingwasseenwithanoscopyatthattime.HewasadmittedtothemedicalfloorreceivedIVfluidsand2unitsofredcells,andisbeingpreparedforacolonoscopytomorrow.Itis2300shiftchange.Theprimarymedicalteamhassignedouttothecrosscoverteam,andthenurseshavejustchangedshifts.Phil,playedbyapatientactor,awakesacutelyshortofbreath.
Patientisinhospitalbed,headofbedup45degreesIVpolewithY‐administrationset;LRononepoint,usedbloodbagonotherIVinonearm(hiddenline)Inhospitalgown,hospitalbottoms,foleylineoutoneleg,50ccurineinbagTelemetryelectrodesonpatientchestfor12leadECG
Bedsidetray:MedicationslistedaboveOxygennasalcannulaandrebreathermaskwithoxygenflowmeterPulseoxprobeforfingerBlooddrawingequipmentandmedicationadministrationaslistedabove
Availablepatientinformation:ChartwithH&PEDChestx‐rayEDlabwork
EveningNurse(Nursingfaculty)handoff(sheet)toNightNurse(s)Primaryintern(PAfaculty),sign‐outsheettomedicalteam
Allfacultywillstepintoscenariotoassistwithmedicalcontenteitherbyrequestorifneededtoguidescenariotocompletion.
Maysuggestteam“huddle”toredirectthescenario.
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Act1:PatientAssessmentbyNurse
“Ican’tsleep”“Wenttothebathroombutbarelymadeit”“Itishardtocatchmybreath““Isatupbutitdidn’thelp”“CanIhavemoreoxygen?”
AvailableResources:Nursehaspost‐transfusionHct30
HR 110BP 148/70Sat% 98–4L/minviaNCor
rebreathermaskRR 32Wt 170
Ventriloscopeormanikinsetting:lungswithloudcrackleshalfwayup
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Act2:MedicalTeamAssessment
“Wokeupshortandcouldcatchmybreath”“Alittleextrapressurefeelingonmychest““WokeupearlieracoupleoftimesSOBbutnotthisbad”“Can’treallytalk”
Rampvitalstothosebelow:HR 120BP 112/68Sat% 92‐‐96%on6LviaNCRR 32
Ventriloscopeormanikinsetting:lungswithloudcrackleshalfwayup
softASmurmur
Lasix• lotsofurine(valveopenedtourineinIVbag)
Nitropaste• BPdropsto92/48
Morphine• BPdropsto104/50
• stableBP
Aspirin• doesnothing
Diphen‐hydramine• doesnothing
FluidsfordecreaseBP
• ifIVrateincreased
“Manitisgettinghardtobreathe”
Resourcesavailable:ChestX‐ray
Cardiomegaly;pulmonaryedema
ECG–NSR;NoST‐elevationABGs–Hypoxia,unchangingOtherlabsaslisted
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Act3:PhilImproves
Act4:Thecross‐coverinternorPAhandsPhil’scarebacktotheprimaryIntern
Rampvitalstothosebelow:HR 100BP 120/72Sat% 95%inon6LNRMRR 24
Ventriloscopeormanikinsetting:cracklesresolve
loudASmurmur
“ManIcanbreathebetter”
“Whathappened?”
“Howismyheart?”
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DataandResults
PhilBrown
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Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:Bloodgases–hypoxiabutnotdeteriorating,repeatvaluesunchangedCBC–Hct30,Hgb12forRNsign‐outsheet,Hct33,Hgb13foradditionalrequestsElectrolytes–normalvaluesandstableBUN,Creatinine‐normalvaluesandstableGlucose‐normalvaluesandstableUA‐normalvaluesandstableCardiacenzymes‐negativeandstableBNP–550ng/L(elevated)EDChestx‐ray–negativeRepeatchestx‐ray–pulmonaryedemaandcardiomegalyECG–tachycardiaonly(noischemicchanges)Anticoagulantstudies–normalvaluesandstable
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ClinicalScenario:APostoperativePatientwithTachycardiaOverview
PaulSmithisa55‐yearoldmanwhonowisPOD#2afteranopencolectomyforStageIIIcoloncancer.Becauseofhishistoryofcoronaryarterydiseaseandseveresleepapnea,hespentthefirstpostoperativedayintheSICU,caredforbytheSICUteam.Hehasdonewell,apartfromoneepisodeofatrialtachycardia,whichresolvedspontaneously.Becauseofthetachycardia,heistransferredtothetelemetryunitasthesurgicalteamisdoingrounds.ThejuniorresidenthasreceivedahandoffcallfromtheSurgeryfellow,buttheteamdoesnotknowMr.Smithwell.Theyarecalledbytheprimarynurse,whotellsthemthatthepatientisexperiencingarapidheartrateandhypotension.
Asthescenariobegins,thechargenurse(faculty)introducestheprimarynursetoMr.SmithandprovidesawrittenhandofffromtheSICUnurse.Theprimarynursebeginsaninitialassessment.Beforetheassessmentcanbecompleted,Mr.Smithstatesthathedidn’tsleepwellthenightbefore,nowdoesn’tfeelwellandisexperiencing“thosepalpitationsIhadlastnight.”Thebedsidemonitorrevealssupraventriculartachycardiawithaheartrateof185‐188b/m,shortnessofbreath,andlight‐headedness.Theprimarynursecallsthesurgicalteamtorelaythisinformation.Thereisafamilymemberintheroomaskingalotofquestionsandtryingtostaywiththepatient.Thenurseobtainsanotherstaffmembertostaywiththefamilymember.
Whentheteamarrives,Mr.Smithisresponsivebutcomplainsofbeinglight‐headed.Theheartrateremainsintheupper180s,andhisbloodpressureis70/50mmHg.Theteamhasaquickhuddletodetermine:1)thepresenceofsupraventriculartachycardiavs.ventriculartachycardia;2) whetherthepatientisstableorunstable;3)thecorrectACLSguidelinestouse;4)needtocallrapidresponse/codeteam.Theteamleaderordesigneemayalsoneedtoexplainwhatishappeningtotheconcernedfamilymemberatthistime.
IfPaulreceivesadenosine,hehas6secondsofasystole,thenrevertsbacktoSVT.Theteamshoulddebriefthatresponse.IfPaulreceivesaseconddoseofadenosine,hewilldeteriorateintoVF.TheteamshoulddebriefandhuddletoachieveasharedmentalmodelofVF.
WhentheteamdecidestocardiovertPaul,heshouldreceivesedationfirst(thiscanberequestorcall‐out).Thefirstcardioversionwillbeineffective.ThesecondcardioversionwillresultinVF.TheteamshoulddebriefandhuddletoachieveasharedmentalmodelofVF.
WhenPaulisinVF,theteamshouldrecognizetheneedtoswitchtodefibrillation(canbeacall‐outorrequest).Acodemustbecalled,androlesassigned(call‐outorrequestfromtheteamleader).Paulwillneedepinephrine/vasopression(call‐outorrequest).After2defibrillationsand2dosesofepinephrineorvasopressin,PaulwillconverttoasinusrhythmandtheBPwillbeabove150/90.
Theteamleader(viarequestorcall‐out)willcalltheSICUfellowtogiveahandoff(SBAR)andrequestatransfertotheSICU.TheR1willgivethehandofftothefellow,andtheprimaryRNwillgiveahandofftothereceivingRN.
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Timeline
5minutes Overviewpatientandtherapyfortachycardia5minutes Introductiontosimulatorandsetting15minutes Runscenario
Act1–InitialevaluationofSVT(5minutes) HandofftoprimaryRNandRNassessespatient(1minute) PatientdevelopsSVTandissymptomatic.RNrecognizesneedforoxygen,monitor,BP
determination(1minute) RNcallsteamandperformsSBAR,teamarrives,quickevaluationandhuddle(3minutes)
Teammayreviewandrequestadditionalinformationaboutthepatientandrequest/performdiagnosticstudies,includingECGandlabs.Bytheendofthisact,theteamshouldhaveasharedmentalmodelofapostoperativepatientwithunstableSVT.Theyshouldrealizetheneedforrapidresponse/codeteamtobepresent.
Act2–ManagementofSVT(4minutes)TheteamwilleitheradministeradenosineorperformDCcardioversion.Ineithercase,thepatientwillremaininSVT,hypotensive,andcomplainingofshortnessofbreath.Asecondattemptofanytherapywillresultinventricularfibrillation(VF).
Act3–RecognitionandmanagementofVF(3minutes)TheteamwillmanageVFusingcurrentACLSguidelines(note:in2011,UWmedstudentsnolongerrequiredtotakeACLS).Afteratleastonedefibrillation,2dosesofepinephrineorvasopressin,andpossiblyonedoseoflidocaineoramiodarone,Mr.SmithwillreturntosinusrhythmwithanadequateBP.
Act4–ReturntosinusrhythmandtransferofcaretoSICU(2minutes)Sharedmentalmodelandadvancedinformationsharing.TheteamshouldcometotheconclusionthatMr.SmithisnowinsinusrhythmbutshouldreturntotheICU.TheteamleadercallstheSICUfellowandgivesahand‐offusingSBAR.TheprimarynursecallstheICUnurseandgivesahandoffusingSBAR.
Debrief–15minutes
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ScenarioParticipants
Medicalstudentsand/orphysicianassistantstudentsA. SeniorresidentB. SurgeryteamPAC. R1D. AdditionalR1orPA(optional)
NursingstudentsA. PrimarynurseB. AnotherfloornurseC. Anothernurseneededforcode
Pharmacystudent: Teampharmacist,whoassistswithmedsduringcode
Studentobservers: remainingstudentsnotassignedarole
Pharmacyfaculty: NeededifpharmacystudentsarenotyetinclinicalrotationsNursingfaculty: Chargenurse,whostartsthescenario&mayneedtonudgeitalongMedicinefaculty: Anesthesiologistwhorespondstocall&mayneedtonudgescenarioAnyfacultyorstaff: Aconcernedfamilymemberpresentintheroom
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ClinicalManagementofUnstableSVTandVT
Onefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementoftachycardiainapostoperativepatient.Thisshouldbeinteractive,andtake<5minutes.
Inthisscenario,we’llbemanaginga55‐yearoldmanwhoispostopday#2afteracolectomy.Hecomplainsofpalpitations,shortnessofbreath,lightheadedness,andhasaheartrateover180b/m.Whatwouldyourinitialstepsbewhenyouseeapatientlikethis?
MajorCausesofTachycardia
Pulmonary PEPneumonia
CV Ischemia(canbe1oor2o)
Metabolic HypokalemiaHyperkalemiaHypomagnesemiaAcidosisVolumedepletion
InitialEvaluation
FocusedH&PReviewimmediateclinicaleventsDiagnostics:ECG,CXRLabs:Chem7,CBC,ABG
Themostcommonreasonsfortachycardiainapostoperativepatientareundiagnosedanemia,potassiumormagnesiumimbalance,acidosis,hypovolemia,orpulmonaryembolism.Whatwouldbeyourinitialstepsforeach?
Anemia checkH&H,administeroxygen,PC,fluids,transfuseifnecessary
Potassiumimbalance checkelectrolytes,correctwithIVpotassium
Lowmagnesium checkelectrolytes,replacewithIVmagnesium
Acidosis checkelectrolytes,ABG,considerantidysrhythmicsorcalcium,correctunderlyingcauseofacidosis
Hypovolemia checkelectrolytes,I/O,replacevolumewithisotonicfluids
PulmonaryEmbolism considerlowdoseanticoagulation,considerimagingstudiesfollowedbyeitherUFHorLMWHandICUevaluationifPEconfirmed
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IntroductiontoSimulatorandScenario
Onefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementoftachycardiainapostoperativepatient.Thisshouldbeinteractive,andtake<5minutes.
SPEAKLOUDfor:1)teamcommunication2)recording(ifapplicable)
A Overviewofscenario“Inthisscenario,you’llbecaringforPaulSmith,a55‐yearoldmanwhohadanopencolectomyforcoloncancer2daysago.HespendthefirstpostopdayintheSICU,becausehehasahistoryofcoronaryarterydiseaseandseveresleepapnea.Hedidwell,apartfromanepisodeofatrialtachycardiawhichspontaneouslyresolved.HeistransferredtothetelemetryunitearlyinthemorningofPOD#2,whenanotherpatientneededtheICUbed.Thefloorteamdoesnotknowthepatient,althoughtheR1receivedahandoffcallfromtheSICUfellow.Thesettingisatelemetryunit.”
B Overviewofequipment“Mr.SmithisplayedbySimMan.Breathsoundsareaudiblehereandhere,usingastandardstethoscope.Heartsoundsareaudiblehere.Theexammaychangeoverthecourseofthescenario.Thisistheautomatedbloodpressurecuffthatisconnectedtothemonitor.YouwillneedtoplaceitonSimManandverballyrequestabloodpressurereadingifyouwantonemeasuredatanytime.Whenyouconnectthetelemetryelectrodeshere,youwillseeMr.Smith’sheartrhythmcontinuously.WhenyouplacetheoximeterontoMr.Smith,youwillseetheoxygensaturationonthemonitor.”
“Medicationsarelocatedonthispharmacycart.Syringes,phlebotomyequipment,andlabtubesarehere.Ifyouareasktodrawblood,youneedtosimulatetheblooddraw.Mr.SmithhasanIVwithastopcocklocatedhere.Ifyouareaskedtoadministermedications,youwillusethisstopcock.”
“Respiratoryequipment,includinganasalcannula,non‐rebreathermask,andanAmbubagareattheheadofthebed.Thereisanoxygenflowmeterhere.”
C Diagnostictestingandresults“Iflabs,CXR,ECG,orABGsarerequested,youshouldgothroughthemotionsofobtainingone.Results(labslip,CXRresults,ECGprintout,ABGslip)willbehandedtotheteamleader.”
D Otheravailabledata“Mr.Smith’sadmissionH&Pandrecentlabsareavailableonthisclipboard.TheR1andprimarynursehavehandoffsheets.”
E Medicationsandothertreatment (Althoughwehadsyringeswithmidazolamandmorphine)“Immediatelyavailablemedicationsareonthiscart.YouwillneedtocallthepharmacytorequestanyotherSTATmedications.Ifyouneedtoadministeramedication,usethisIV.”
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“IfMr.Smithrequirescardioversionordefibrillation,hereisastandarddefibrillator,whichyoushoulduseasyounormallywould.Verballycalloutthedesirednumberofjoules,butbesurethatthechargeneverexceeds20joules.”
F Questions?
G Introducetheparticipants(sometimesitworksbettertoassigncodeteamrolesatthebeginningofthescenario:Teamleader,chestcompressions,airway,defibrillatormanager,medRN,recorder)
“Wewillhave6studentsparticipate.____istheseniorresidentonthegeneralsurgeryteam,and____istheR1whogotahandofffromtheSICUfellow.____isthefulltimesurgeryPA.____isthepatient’sprimarynurseontheteleunit,and____isanothernurseavailabletohelp._____isthegeneralsurgeryteampharmacist.Facultyalsohaveroles:____,oneofournursingfaculty,willplaythechargenurse,and____,oneofourstaff,willplaytheroleofMr.Smith’sdaughter.____,oneofourmedicalfaculty,willplaytheattending.”
“Observersneedtobealertforexamplesofgoodcommunicationtechniques,orlackofcommunicationtechniquesduringthescenario.Lookforexamplesofthefollowing:
Requests Crosschecks Checkbacks Callouts SBAR
Briefs Debriefs Huddles
Mutualsupport CUS 2‐ChallengeRule DESC‐It
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DebriefingTips
(seeTeamSTEPPSdebriefforteamcommunicationobjectivespages8‐15)
ClinicalDebrief
Whatwasgoingon?Whatsupportsthis?Whatelsewereconsidering?
PauldevelopsanunstableSVTfollowinganightintheSICUwherehealsohadaself‐limitingepisodeofatrialtachycardia.Presenceofshortnessofbreath,lightheadedness,andhypotensionshouldpointtheteamtousetheACLSguidelinesforunstableSVT.Paulisstillresponsive,soshouldreceivesedationpriortocardioversion.
Hypoxemiaisapossibility,buthisoxygensatsaresatisfactorywhenoxygenisadministered.
RespiratoryacidosisisrevealedinanABGobtainedwhenBMVisinplace.Hehasseveresleepapneaandcomplainedofpoorrestthenightbefore.ThereisnoindicationthatheusedhisBi‐PAPmachineintheSICU,socouldhavebeenretainingCO2.Theacidosisimprovesonceheisintubated,andhisPaCO2normalizes.
It’spossibleforPaultobeanemicfollowingcolectomy,butcurrentHctis32%.
Howdidevaluation&managementgo?
Commonmanagementproblemsinclude:1. ConcludingthatthepatientisinventriculartachycardiaratherthanSVT.Examination
oftheinitialECGshouldrevealthepresenceofclearlyvisiblePwavesinLeadsII,III.2. Administeringadenosine(ACLSguidelineforstableSVT)totreatunstableSVT.Current
ACLSguidelinesrecommendsynchronizedcardioversion.3. Omittingsedationpriortosynchronizedcardioversion.Thepatientisawakeand
responsiveandshouldbesedatedpriortocardioversion.4. Forgettingtopushthe‘sync’buttononthedefibrillatorpriortocardioversioneach
time.5. Omittinganantidysrhythmicmedicationwhentreatingventricularfibrillation.
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MedicalTeamHandoffSheet
Patient ProblemList Medications Plan
Smith,PaulUxxxxxxx
5NE
1. POD#2opencolectomy2. StageIIColoncancer3. OSA–usesBiPAPat
night4. Diabetes5. CAD–IMI1yearago6. COPD7. Allergies:
a. PCNhivesb. Beestingswheeze
c. Morphine,Percocetnausea
Atenolol100mgdaily
ASA81mgdaily
Lipitor40mgdaily
Lasix20mgdaily
Metformin1000mgtwicedaily
Albuterol/atroventMDIfourtimesdaily
Advair1pufftwicedaily
Epipenprn(homemed)
1. Re‐checkCBC,chem7,ECGinam,considerK/Mgprotocol
2. SupplementalO2,BiPAP
3. Progressiveambulationandactivity
4. Progressdietwhenbowelactivityresumes
NursingHandoffSheet
Patient ProblemList Medications Plan
Smith,PaulUxxxxxxx
5NE
1. POD#2opencolectomy2. StageIIColoncancer3. OSA–usesBiPAPat
night4. Diabetes5. CAD–IMI1yearago6. COPD7. Allergies:
a. PCNhivesb. Beestingswheeze
d. Morphine,Percocetnausea
Atenolol100mgdaily
ASA81mgdaily
Lipitor40mgdaily
Lasix20mgdaily
Metformin1000mgtwicedaily
Albuterol/atroventMDIfourtimesdaily
Advair1pufftwicedaily
Epipenprn(homemed)
1. HavefamilybringinBiPAP
2. Respiratorytherapytoevaluate
3. FSBGevery6hours4. Orderlabs,ECG5. Dangleatsideofbed
thisam,uptochairthispmMonitorforreturnofbowelfunction
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SurgicalClinicHistoryandPhysicalforPaulSmith
(Fordesktopcomputerorhardbackchart)
ID/CC:Mr.Smithisa55yomalewithahistoryofCAD,COPD,diabetesandsevereobstructivesleepapneascheduledforalaparoscopicpartialcolectomywithlymphnodebiopsiesforcoloncancer.Hiswork‐uptodateisnegativeformetastaticdisease.
HPI: 3weekspriortoadmission,Mr.SvisitedhisPCP,complainingofabdominalpainandconstipationforthepast1‐2weeksandbrightredbloodinthestoolX2days.Rectalexamatthatvisitshowedblood,andhewasreferredforanurgentcolonoscopy.Thisshowedastrictureinthedistalsigmoidcolon.Biopsyrevealedadenocarcinoma.AnabdominalCTshowedanareaofthickeningandnarrowinginthesameregion,butnoclearevidenceofmetastaticdisease.Hewasreferredforpartialcolectomyandlymphnodedissection.
PastMedicalHistory:
1. Coronaryarterydisease– InferiorMI1yragobutnocurrentchestpainorSOB.CathatthetimeofMIshowedcompleteocclusionofRCA,50%occlusiondistalLAD.Nointervention.EchoshowedEF52%,withinferiorhypokinesis.Otherwisenormal.
2. Hyperlipidemia3. HTNfor15yrs4. DM–5years.Controlledonmetformin,withlastHgbA1cof6.8.5. Obesity–BMIof346. SevereObstructiveSleepApnea,onCPAP7. COPD,withmostrecentFEV165%predicted.Norecentexacerbation.Has
neverrequiredsteroidsorintubation.
PastSurgicalHistory:
1. Appy,age28
Medications: 1. Atenolol100mgdaily2. ASA81mgdaily3. Lipitor40mgqd4. Lasix20mgqd5. Metformin1000mgPObid6. Albuterol/atroventMDIqid7. Advair1puffbid8. Epipen(homemed)
Allergies: PCNhivesBeeStingswheezingMostpainmeds–morphine(notmorphone),Percocet–maybenausea?
SocialHistory:
1. OccasionalETOH2. 30packyearhistory,quitsmokingafterhisMIbuthasbeensmokingabit
withthestressofhissurgery3. Marriedwiththreeteenagechildren
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4. Exposures:none5. Diet/Exercise:“Notthebest–workingonit”6. Immunizations/Health/ContinuityofCare:Uptodateonimmunizations;
seesaPCPbutnotregularlyforhisOSA,diabetes,hyperlipidemia(Butheactuallyvisitedhiswife’sprimaryphysicianforcurrentproblem)
FamilyHistory:
Father(alive,80’s): HTN,HyperlipidemiaMother(alive,80’s:DMsomewhatcontrolledBrother(alive,50’s):HypertensionSister(alive,50’s):Healthy
ROS: CV:+peripheraledemaResp:+dyspneaonexertionwithclimbingoneflightofstairsAllothersnegativeexceptasperHPI–seeROSform
PhysicalExam:
ObesebutwellappearingmaninnoacutedistressVS: 148/88 76 16 97%onRAHEENT:lowhangingsoftpalate,severalmissingteeth,thickneck.Heart:RRR,normalS1andS2,noS3orS4,nomurmurLungs:clearAbd:obese,soft,nontender.Nohepatosplenomegaly.Ext:1+LEedema
Imaging: CTScanofMay27reviewedwithDr.Jonesandradiologyattending.
Lab: Normaltumormarkers,Chem7. Hct32withMCV77;otherwisenormalCBC
Assessment: 55‐year‐oldmanwithmultiplestablemedicalproblemsandanewdiagnosisofcoloncancerwithoutobviousmetastaticdisease.
Wewillattemptalaparascopicpartialcolectomy,convertingtoopenifanatomyorrespiratorystatusrequires.
Heandhiswifewerecounseledthatthisisahigherriskproceduregivenhismedicalissues.Consentsigned,surgeryscheduledforJune1.
Plan: 1. Pre‐surgeryclinicvisittomorrow2. Aspirinstopped5daysago3. Pre‐oplabs:CBC,coags,chem7,EKG4. BowelPrep:Go‐Lytely3L,pre‐openema5. NPOaftermidnight6. ORJune1
Equipment
Simulator: SimManwithsoundsystemsoitcananswerquestions
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withIVline,IVbagfullComputerwithmonitor,ifrequestedwithonscreeniconsfor:
H&PAcutelabsheet
CXREKG–oldinferiorMI
RoomSetting Mannequinonhospitalbed Mannequinshouldhaveanabdominaldressing(Paul
Smithhadanopencolectomy) Hospitalgown Pillow Sheets Blanket
Attheheadofthebed non‐rebreathermask nasalcannula suctioncanister Yankeursuctiontip stethoscope Bloodpressurecuff pulseoxsensor
Codecart,andadefibrillatorontopofthecodecartStepstoolBedsideTrayChairforfamilymemberBPCuffStethoscopeVitalSignsMonitor
Respiratoryequipment Nasalcannula(alsolistedaboveinRoomSetting)Non‐Rebreathermask(alsolistedaboveinRoomSetting)OxygensourceIntubatingequipment–meshbagAmbuBagOxygenflowmeter
Operational(orpretendequivalent)telephonewithpostedphonenumbersfor:
Phonenumbertolab(personansweringneedslabresultsandneedstoknowthattherearebloodtubesthatadditionallabscouldbeaddedto)
IVequipment IVpoleIVinfusionlineIVbag(LR)X4ABGkitX2
Medicationsandequipment:
Syringes:3mlX5;5mlX5;10mlX5
Medications
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Propofol 20mlsyringesX2Pentothal 20mlsyringesX2Succinylcholine 20mlsyringeX2,10mlineachRocuronium 10mlsyringeX1Fentanyl 5mlsyringeX2Versed 5mlsyringeX2Morphine 5mlsyringe(labeled1mg/ml)X2
CodeDrugs: epiXmanyvasopressin40unitsX4lidocaineXmanyamiodarone:150mgX4;300mgX2atropineXmanycalciumXmany
Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:
H&PforMr.SmithAdditionalInfosheetforstandardizedpatientECGfromthe1stpostopdayshouldshowanoldinferiorMICXRnormal55yochestAcuteLabprintout:CBCnl,Chem7nlwithKof3.4mEq/LABGresultslipsX2
ifpatientbag‐maskventilatedduringcodeifpatientintubatedduringcode
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Storyboard
PaulSmithisa55‐yearoldmanwhonowisPOD#2afteranopencolectomyforStageIIIcoloncancer.Becauseofhishistoryofcoronaryarterydiseaseandseveresleepapnea,hespentthefirstpostoperativedayintheSICU,caredforbytheSICUteam.Hehasdonewell,apartfromoneepisodeofatrialtachycardia,whichresolvedspontaneously.Becauseofthetachycardia,heistransferredtothetelemetryunitasthesurgicalteamisdoingrounds.ThejuniorresidenthasreceivedahandoffcallfromtheSurgeryfellow,buttheteamdoesnotknowMr.Smithwell.Theyarecalledbytheprimarynurse,whotellsthemthatthepatientisexperiencingarapidheartrateandhypotension.
Act#1–IntroductiontoPatientPatientisadmittedtotelemetryunitandplacedonmonitorpertheunit’sstandardofcare.
Initialvitals(frompatientchart,notonmonitoryet):
BP140/76vitalsdeterioratetoBP82/40HR102 HR185RR22 RR30Sat98%RA Sat87%RAT38.0
Patientinbedspeakingwithfamilymember
“Didn’tsleeptoowelllastnight;wokeupacoupleoftimesandfeltmyheartracing,andfeltalittlewoozy.Can’tseemtocatchmybreathwithallthiscrapI’mcoughingup”
Act#2–SupraventricularTachycardiaMonitorshouldautomaticallyshow:
VitalSigns:HR188RR34Sat88%
RNorMDwillaskforBP,whichshouldshowBP75/40
Teamshouldbecalledandhaveahuddle.Whentheyarrive
(Anxious)“Holymackerel,myheartisracingagain”
“Idon’tfeelsogood,mychestissoheavy…”
“IfeellikeI’mdying,oh,Jesus”
Iftheteamfailstosyncresultingindefibrillationratherthancardioversion,thenstayinAct2forupto2shocksthengotoAct4VentricularFibrillation.
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Mayneedtopromptparticipantstosedatewithmidazolam
Shouldgiveoxygen
IfAdenosineisgiven
IfSyncCardioversion
Sats98%withoxygen,88%without
Act#3:AdenosinetoSVT
Vitals:
Rhythm–asystolefor6‐8sthenbacktoSVTHR–188BP–75/40Sat–88%
Act#3:CardioverttoSVT
Vitals:
Rhythm–SVTHR–188BP–75/40At–88%
“Wow,thosepaddlesarecold,isthisgoingtohurt?”
Onseconddoseofadenosine
Onsecondcardioversion.
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Act#4:VentricularFibrillationMayneedtopromptparticipantstohavea2ndhuddle,perhapscallAttendingforassistance
Vitals:
Rhythm–VentricularFibrillationHR–0BP–0Sat–85%
After:DefibrillationAnd
atleastoneroundofVasoorEpi
And2RoundsofLidoor
Amio2nd Defibrillation
Act#5:PostV‐Fib,Ptlives!– TransfertoICU
MayneedtopromptparticipantstoperformhandofftoSICUfellow/SICURN
Rhythm– normalsinusSTdepressionMultifocalPVC’s
HR–125BP–170/100Sat–94%
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DataandResults
Fromhttp://en.ecgpedia.org/
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RADIOMETER ABL800 FLEX ABL825 C 09:06 9/14/2009 PATIENT REPORT CODE/Customized - S Sample # 18330
195uL
Identifications Accession No. Patient ID Patient Last Name Patient First Name
Sex Date of birth Patient note Physician Department Department (Pat.) Sampler ID Approval Note Sample age Draw time ICD9 Code Diagnostic Code Sample site Sample type T 37.0 °C PEEP Operator
Note __________________________________________________________
Blood Gas Values pH 7.100
pCO2 65.0 mmHg pO2 125 mmHg cHCO3
-((P)C 19.0 mmol/L cBase(B)C -7.0 mmol/L
Oximetry Values Hctc 36.0 %
ctHb 12.0 g/dL FO2Hb 98.1 % FCOHb 1.4 % FMetHb 0.5 % ctO2C 16.7 Vol% sO2 100.0 %
Electrolyte Values cNa+ 132 meq/L
cK+ 3.4 meq/L cCa2+ 1.11 mmol/L Metabolite Values cGlu 148 mg/dL cLac 1.99 mmol/L Temperature Corrected Values pH(T) 7.430
pCO2(T) 34.8 mmHg pO2(T) 238 mmHg
Notes c Calculated value(s)
Printed 9:18:27 09-09-14
*If Bag-Mask Ventilated
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RADIOMETER ABL800 FLEX ABL825 C 09:06 9/14/2009 PATIENT REPORT CODE/Customized - S Sample # 18330
195uL
Identifications Accession No. Patient ID Patient Last Name Patient First Name
Sex Date of birth Patient note Physician Department Department (Pat.) Sampler ID Approval Note Sample age Draw time ICD9 Code Diagnostic Code Sample site Sample type T 37.0 °C PEEP Operator
Note __________________________________________________________
Blood Gas Values pH 7.230
pCO2 45.0 mmHg pO2 185 mmHg cHCO3
-((P)C 20 mmol/L cBase(B)C -4.0 mmol/L
Oximetry Values Hctc 36.0 %
ctHb 12.0 g/dL FO2Hb 98.1 % FCOHb 1.4 % FMetHb 0.5 % ctO2C 16.7 Vol% sO2 100.0 %
Electrolyte Values cNa+ 132 meq/L
cK+ 3.4 meq/L cCa2+ 1.11 mmol/L Metabolite Values cGlu 114 mg/dL cLac 1.99 mmol/L Temperature Corrected Values pH(T) 7.430
pCO2(T) 34.8 mmHg pO2(T) 238 mmHg
Notes c Calculated value(s)
Printed 9:18:27 09-09-10
*If Intubated
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ClinicalScenario:ATeenagerwithAsthmaOverview
MicahStevensisa16‐yearoldwithsevere,persistentasthmawhowalksintotheEDwiththreedaysofcough,runnynoseandonedayofwheezinguncontrolledbyalbuterolMDI.Micahisportrayedbyasimulator,voicedbyaremotetechnician.
Asthescenariostarts,thetriagenurse,playedbyafacultynurse,announcesMicah’sarrivalintheER,saying“Hedoesn’tlooksogoodandtheattendingisseeinganacuteMIinroom12–youguysoughttoseehimnow.”Theteamevaluatesandtreatstheasthmaexacerbation,withmanyopportunitiesforclosedloopcommunication,informationsharing,andprovidingmutualsupport.
Unfortunately,evenwithoptimalmanagement,hebecomesprogressivelymoretiredanddevelopsarespiratoryacidosis.Heshouldbeintubated,byafacultymemberactingastheanesthesiaattending,whoperformsaRmainstemintubation.Thesimulatorlosesbreathsoundsontheleft,whichmustberecognizedbytheteam.Theanesthesiaattendingisinitiallyunwillingtoadmitthemistake,andmustbechallengedtwice.Ultimately,theerroriscorrected,MicahisstabilizedandhiscareishandedofftotheICU,anopportunitytopracticeaninterteamhandoff.
Heliveswithhiscustodialgrandmother,portrayedbyanactor,whowillarriveintheEDafterheisintubated.Theteammustdeliverthenewsofhisconditionandobtaininformationfromher.
ThereissomeconcernaboutMicah’sadherencetotherapy.Heisatypicalteenagemale,independentandnotwillingtobesupervisedinusinghismeds.HeattendshisPulmonaryClinicvisitsalone,ashisgrandmotherworks.Athislastpulmonaryclinicvisit,hisdoctorraisedconcernsaboutcompliancewithAdvair.ThepharmacystudenthastoexploreMicah’sgrandmother’sunderstandingofhisinhalerprescriptionanduse.
Thefocusofthescenarioshouldbeonthecommunicationbetweenteammembers,notthemedicalmanagement.
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Timeline
5minutes Briefintroductiontoclinicalproblemandoverviewofmanagement
5minutes Introductiontosimulatorandsetting
15min Runscenario
Act1:Initialevaluationandmanagement(4minutes)Option:ThePAcanfirstevaluateandthenconsulttheR1.
Act2:ClinicalDeterioration(4minutes)
Act3:RMainstemIntubation(Rmainstem)(3‐7minutes)TheERPAoroneoftheR1s(participantsA,B,CorD)willbeaskedtocheckforbreathsounds,whicharenowabsentontheL.Ateammembershouldchallengetheanesthesiaattendinguntilcorrected.
Act4:HandofftoICU(2minutes)TheERPAoroneoftheR1s(participantsA,B,CorD)willbecalledtothephonebythefacultyRNtotalktotheICUfellow.
Act5:Discussionwithgrandma(5minutes)TheprimaryERnurse(participantE)isasked(viaoverheadspeakerorfacultyRN)togotothewaitingareatotalkwithgrandma.TheERPAoroneoftheR1s(participantA,B,CorD)willalsobeaskedtotalktograndmabyfacultyRNTheERpharmacist(participantG)willalsobepulledintothediscussionwithgrandmotherbythefacultyRN,givenconcernsovermedicationadherence,whichshouldbeexploredasallowedbytimeandthesituation.
15minutes Debrief
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ScenarioParticipants
StudentParticipants(nametagswithnameandLARGELETTERS):3‐4 Medical/PhysicianAssistantstudents
A. R1.B. R1.C. ERPA(optional)D. AdditionalR1(optional).
1‐2 NursingstudentsE. PrimaryERnurseF. AnotherERnurse
1 PharmacystudentG. ERpharmacist
Actor:Grandmother,Katherine.
FacultyParticipants:AnursingfacultymemberwillactastheERchargenurse,startingthescenariobycallingtheERteamintothe‘room’,saying“I’vegota16yearoldkidherewithanasthmaexacerbation.IgotaCXRandcalledhisgrandma,andhadhimusehisinhaler.He’snotlookingtoogoodandtheattendingisseeinganacuteMIinroom12–you’dbettercomeseehimnow”
Amedicinefacultymemberactsastheanesthesiaattending,intubatingthepatientwhencalledtodoso.Heorsheisreluctanttoadmitandcorrectthemainstemintubation.
AnyfacultymembercanplaytheX‐raytech,whowill‘performanx‐ray’ifrequested,andpullituponcomputerfortheteamtoreview.
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ClinicalOverviewofAsthmaExacerbation
OnefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementofanasthmaexacerbationintheED.Thisshouldbeinteractive,andtake<5minutes.
“Inthisscenario,we’llbemanaginga16yearoldwithsevere,persistentasthmawhopresentstotheEDwithanexacerbation.Whatwouldyourinitialstepsbewhenyouseeapatientlikethis?”
Placeonmonitor,obtainIVaccess,placeO2 Begintreatment:
o Inhaledbronchodilators: Betaagonist(usuallyalbuterol)vianeborMDI,every20minutesx3 Ipratropiumprobablyalsohelpful
o Systemicsteroidsimmediatelyforsevereexacerbation,orifthereisnotapromptresponsetobronchodilatorsforalesssevereexacerbation.
Assessseverity:o Physicalexamfindingsareinsensitiveforasevereexacerbation,butifpresent,are
veryconcerning:accessorymuscleuse,inabilitytolayflat,diaphoresis.Sometimeswheezingwillgrowsofterasseverityworsens,becauselessairismoving.
o Checkpeakexpiratoryflow.<40%ofpersonalbaselinedefinesasevereexacerbation
o AnABGtoevaluateforhypercarbiaifthereisanyclinicalindication(somnolence,confusion,rapidshallowbreathing)ORlowPEFRORfailuretorespondtobronchodilators
Frequentreassessmentofresponse
“Whatwouldindicatethepatientneedstobeintubated?” <5%ofpatientsover12whovisitanERforasthmarequireintubation;however,shouldn’t
waituntilobviousrespiratoryfailuredevelops Hypoxiadespiteoxygentherapy Hypercarbia RapidshallowbreathingandobviousfatiguewithahighorevennormalCO2 Alteredmentalstatus Cardiacorrespiratoryarrest
“Howwouldweexpectateenagerwithsevere,persistentasthmatobemanagedasanoutpatient?” Highdoseinhaledsteroid Inhaledsalmeterol Inhaledalbuterolprn +/‐montelukast
“Inthiscase,thepatientisprescribedAdvair(salmeterol‐fluticasone+albuterolprn)
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IntroductiontoSimulatorandScenario
Onefacultymembershouldintroducethestudentstothesimulationscenarioandequipment,insomedetail.Thisintroductionshouldcover:
SPEAKLOUDfor:1)teamcommunication2)recording(ifapplicable)
A Overviewofscenario:“Inthisscenario,you’llbecaringforMicahSteven,a16yearoldwhowalksintotheERwithanexacerbationofchronicpersistentasthma.ThesettingisanERroom,withstandardERequipmentandmedications.”
B Overviewofequipment:“Micahisasimulator.Breathsoundsareaudiblehereandhere,usingastandardstethoscope.Heartsoundsareaudiblehere.Theexammaychangeoverthecourseofthescenario.Thisistheautomatedbloodpressurecuffconnectedtothemonitor.YouwillneedtoplaceitonMicahandpress“start”andcalloutarequestforabloodpressureifyouwantonemeasuredatanytime.Otherwise,ifthecuffisonMicah,anewbloodpressurewilldisplayeveryseveralminutes.IfyouplaceMicahontelemetry,hisrhythmwillalsodisplay,andifyouplacehimonanO2satmonitorsatswilldisplay.”
“Medicationsarelocatedonthispharmacycart.Syringes,phlebotomyequipment,andbloodtubesarehere.Ifyouareaskedtodrawbloodoradministermeds,gothroughthemotions,butdon’tactuallypunctureanythingorpushanymeds.”
“Respiratoryequipment,includingnasalcannula,anonrebreathermask,andanAmbuBagareattheheadofthebed.”
C Diagnostictestingandresults“Iflabs,chestx‐ray,ECGorbloodgasarerequested,youshouldgothroughthemotionsofobtainingone.Resultswillbecalledoutwhenavailable,anddisplayedonthecomputermonitor.IfyouwantanECG,hereisthemachine.YouwillbehandedaprintoutoftheECG.Ifyouwantachestx‐ray,requestone.Youwillbenotifiedwhenthefilmisavailable–itwillbepulleduponthecomputermonitor.”
D Otheravailabledata“TheERtriagesheetisontheclipboardintheroom.Thelastpulmonaryclinicnoteisavailableonthedesktop(orinhardbackchart).
E Medicationsandadministration“Immediatelyavailablemedicationsarehereonthispharmacycart.YouwillneedtocallthepharmacytorequestanyotherSTATmedications–itisimportanttoconsultpharmacyforthedose.Ifyouneedtoadministeramedicationjustgothroughthemotions.
F Questions?
G Introducetheparticipants
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“Wewillhave6studentsparticipate.____and____areinternsrotatingintheER.____isthefulltimeERPA.____isthepatient’sERnurse.____isanotherERnurseavailabletohelp.____isoneoftheERpharmacist.Threefacultyalsohaveroles:____,oneofournursingfaculty,willplaytheERchargenurse.
H Startingthescenario:“Micahhasbeentakenbacktoaroomimmediatelyfromthetriagedesk.Teammembersarehangingout,waitingforpatientstosee,whentheERchargenurseapproachesthem.”
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DebriefingTips
(seeTeamSTEPPSdebriefforteamcommunicationobjectives)
WhatdidyouthinkwasgoingonwithMicah?Whatsupportsthis?Whatelsewereyouconsidering?
MicahhasinspiratoryandexpiratorywheezesthroughoutwithincreasedRR>24.Hemightneedanebulizertreatment.Ifthenebulizers'donotworkthenhemightneedanotherdrug,steroidsandorintubation.
Whatsupportsthisandwhatareyouconsidering?
Lungssounds,CXRandABGsneedtobeordered.Steroidsinadditiontonebs.IfheneedsintubationhewillneedAnesthesia,sedation,postintubationABGS,CXR.FollowupwithFamilyregardingmedicationuseandcompliance.
Howdidyourevaluationandmanagementgo?
1. DidMicahrespondtothefirstdoseofnebs?ifyesgreat!Ifnotthenheneedsanotherdoseandorsteroids
IfNo:hewillneedmoremedicationsandpotentialintubation‐@intubationtimetherecanbeanissuewithETplacementandrepositioningisneededwithrepeatCXRandABGs.
Familymember:Grandmahasinformationabouthisinhaleruse
Commonproblemsinclude:
1. noncompliancewithinhaleruse2. intubationneededduetopoorresponsetosteroidsandnebs3. PostintubationETmisplacedandneedsrepositioning4. GrandmaarrivesandwantstostaywithMicahevenduringintubationandstaffneedto
addressher. Ask:HowdidyoudecidetodealwiththeGrandmabeingintheroom?
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Micah:HistoryandPhysical
HejustarrivedtotheERsonoH&Phasbeentakenyet.
ERTriageSheet
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InformationforSimulationTechVoicingMicah
Initialresponsetoanyopenendedquestion
(deliveredinabreathlessway)
Ihavehadacoldforacoupleofdays,butIthinkithasgottenworsetoday.
Sincelunchithasgottenworseandworse,andIcanhardlybreathenow
Anyothersymptoms? No
Whatmakesitbetter? Nothing,infactIdon’tthinkmyinhalersareworking– IusedtheAdvair3or4timestodayanditdidn’treallyhelpatall
Whatmakesitworse? Walking,talking
Anythinglikethishappenbefore?
Ya,acoupleoftimesIthink,butnotthisbad
Whatdoyouthinkisgoingon?
It’smy‘friggin’asthma
Ifaskedspecifically,youDO:
Havearunnynose,sneezing
Ifaskedspecifically,YOUDONOTHAVE:
AnyothermedicalproblemsActive,athletic–pickyoursportandtalkaboutit
Ifaskedspecificallyaboutyourinhalers,
Youareabitvagueonhowyou’reusingthem.TheAdvairshouldbetwiceaday,andthealbuterolshouldbetheoneyouusewhenyou’reshortofbreath.Youareusingtheadvairnotsoconsistently,andsometimesyou’reusingitratherthanthealbuterolforacutesymptoms(whichisexactlythewrongthingtodo).
PersonalHistory IwasbornandraisedinSeattle,goto(yourhighschool). Iliketoplay___buthaven’tbeenabletoforacoupleofmonths‘causeI’vebeenabittoowinded.
Meandmysisterhavebeenlivingwithmygrandmaforthelastcoupleyears,becausemymom’shadtroublewithdrugs.She’sdoingbetternow,andweseealotmoreofher.Grandma’sstillworkingeventhoughsheshouldberetiredbynow.It’sbeentoughforhertotakesomuchtimeofftotakemetoappointmentsandstuff.
Habits Don’tsmokeDon’tusedrugs–Iwouldneverdothatwithwhat’shappenedwithmymomDon’tdrink
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SexualHistory ‘Whatever’….
FamilyHistory Mymomishealthyexceptforthedrugsandshe’sdoingalotbetternow.Mydadisoutofthepicture.Mygrandma’shealthyandso’smysister
PastMedicalHistory I’mreallyprettyhealthy,justthisasthmathing,beeninthehospitalmaybe3timesforit.
Seemstobeworsethislastyear
Medications: 2inhalers,advairandalbuterol,vagueoncorrectuse– seeabove.
Allergies: none
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InformationforActorPlayingMicah’sGrandma
Overview:A16‐yearoldwithahistoryofasthma,Micah,walksintotheEDonhiswayhomefromschool.Hehashadacoldforacoupleofdays,andaonedayhistoryofwheezinguncontrolledbyhisinhalers,andincreasingshortnessofbreath.
Hebecomesprogressivelymoreshortofbreathandiseventuallyintubated.Hehasarightmainstembronchusintubation(meaningthetubehasgoneintoofar,andtheleftlungdidn’tgetanyairforaperiodoftime.Thisisanundesirablebutfairlycommonevent.Theclinicianlistensoverbothlungsandchecksachestx‐raytoensurethetubeisintherightplace.)HeisthenstabilizedfortransfertotheICU.
TheERtriagenursecalledyouwhenMicahfirstcamein.YouarriveintheEmergencyRoom.
Atthispoint,yourgrandsonisclinicallystable.3clinicianswilltalkwithyou:
1. TheERnurse,whowillapproachyou,ensureyouareokayandtellyouabitaboutthesituation.
2. The“resident”(playedbya4thyearmedicalstudentorphysicianassistantstudent)whowilltellyouaboutMicah’sERcourseandwhattoexpect.Thisisa‘deliveringseriousnews’discussion,oftheneedforintubation,ICUadmission,andtherightmainstemintubation,whichhasnowbeencorrected.Youarecalmbutworried,andaskquestionsabouthowhehasbeentreated,howheisdoing,andwhatyoushouldexpect.Youalsoaskaboutwhatcanbedonetopreventanotherepisodeasbadasthis.
3. The“pharmacist”(playedbya4thyearpharmacystudent)whowillaskyoumoreaboutMicah’sinhalersandhowhewasusingthem.Youwanttoknowwhyhismedicationsdidn’tabortthisattack.Thepharmacistisconcernedthatincorrectuseofmedicationsmayhavecontributed(i.e.hemayhavebeenusingthelongactinginhaler(Advair)ratherthantheshortacting‘rescue’inhaler(albuterol)whenhefeltmoreshortofbreath).
Micahis16,andquiteindependent.Hehasbeenadministeringhisowninhalersforthepast3years,andbecomesannoyedifyouaskorremindhimaboutthem.Youthinkthathetakesthemasdirected,butcometothinkofit,youhaven’thadtopickuparefillontheAdvairforawhile.Youdidnotnoticeanythingunusualbeforeyouleftforworkthismorning–hewasoutofbedandintheshower
SeebelowfordetailsofMicah’smedicalhistory,fromhismostrecentPediatricPulmonaryClinicnote.
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EquipmentandSupplies
Simulator: LaerdalNursingKellyorLaerdal3G Wearingahospitalgown SoundsystemtovoiceMicah FakeIVline
VitalsignsmonitorrunningSimMansoftwaretodisplaytelemetry,vitalsign
SETTING Simulatoronagurney pillow sheets blanket
Respiratoryequipmentatheadofgurney(seebelow)
Operational(orpretendequivalent)telephonewithpostedphonenumbersfor:
AnesthesiaCriticalcarefellow
Computerwithmonitorandon‐screeniconsorprintedchartcopiesof:
LastpulmonaryclinicnoteAcutelabresultsCXRECG
Vitalsignsequipment MonitorrunningSimMansoftwareBPcuffStethoscope
Respiratoryequipment Respiratoryequipment(atheadofgurney) Oxygenflowmeter Nasalcannulae Nebulizerdevice Airoroxygensourcefornebulizer Nonrebreathermask AmbuBag Suctioncanister Yankeursuctiontip Intubatingequipmentbag,totheside
IVequipment IVpoleIVinfusionlineIVbag(LR)X4
Medicationsandequipment: SalinefishlabeledAlbuterol 3fishSalinefishlabeledAtrovent 3fishSolumedrol 1amp
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Propofol 20mlsyringesX2Succinylcholine 20mlsyringeX2,10mleachRocuronium 10mlsyringeX1Fentanyl 5mlsyringeX2Versed 5mlsyringeX2
Labdrawequipment ABGkitX2Syringes:3mlX5;5mlX5;10mlX5
Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:
Papercopiesof: ECGshowingsinustachycardia CXR a.)hyperexpanded16yocxr
b.)showingRlungcollapseincaseRmainstemnotaddressed
AcuteLabprintout:CBCnl,Chem7nl ABGresultslipsX2
VerymildrespiratoryacidosisandnormalpaO2Moresevererespiratoryacidosis
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PediatricPulmonaryClinicNote
(Fordesktopcomputerorpaper)
PediatricPulmonaryClinicNote,March2Thisisanoverduefollow‐upvisitforMicah,a16yearoldwithseverepersistentasthma.SincelastseeninDecember2010,hehasdonesomewhatbetter.HehasbeenseenintheEDonce,inJanuary,withanasthmaexacerbationinthesettingofaURI.HewastreatedwithIVsolumedrol,nebulizers,anddischargedwithasteroidburst.HehashadnoERvisitsorsteroidtreatmentsincethattime.
Overthecourseofthelastyear,hehashad3ERvisitsand5coursesofprednisone.Heshouldbeseenmonthly,buthasnotshowedforthelastcoupleanddidn’treschedule.Hewasbroughttotheclinicandsignedinbyhisgrandma,whohascustody,butshehadtoreturntoworkbeforehewasseen.
Hehasbeenabitmorelimitedinhisactivity.He’snolongerplayingsoccerbecausehefeelstooshortofbreath.MissedlastscheduledpulmonaryfunctiontestsinOctober,andhasn’trescheduled.
UsinghighdoseAdvair,prescribedbid,butheseemstobeusingitonceonmostdays.Usesalbuterolalmosteveryday,sometimesmorethanonce.
PMHx: Asthma,diagnosedatage7.Appendectomy,2007
Meds: Advair(salmeterol‐fluticasone)250mcgbidAlbuterolinhalerasneeded
SocialHx: Liveswithgrandma,Katherine,whoworksasanadministrativeassistantathisschool.Herworkschedulemakesittoughtoattendappointmentswithhim–sheusuallysignshiminandreturnstowork.10thgrade,doing‘okay’inschool.Nolongerplayingsoccerbutenjoyschess.Hopestoattendcollege.InsurancecoverageisMedicaid.
Physicalexamination:Overweightteenager,looksprettywell.Height175cmWeight95kgBMI31 BP124/76 HR78O2sat97%Heart:RRR,normalS1andS2,noS3orS4Lungs:scatteredexpiratorywheezing,betterafterapuffofalbuterol.Goodairmovement.Abdomen:normalExtremities:noedemaAssessment:Micahisa16yearoldwithsevere,persistentasthmaandmultipleexacerbationsoverthepastyear.He’sdonebetterinsomewaysoverthepastfewmonths,withfewerEDvisitsandsteroidbursts.However,heisnolongerabletoplaysoccerandhassomewheezingtodayonexam.I’mworriedabouthiscompliance,givenamissedappointment,missedPFTs,andlackofclarityonhowheuseshisinhalers.
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Plan:1. ReeducatedMicahoninhalerusetoday.Willcontactgrandmaandseeifwecan
schedulehisnextapptatatimeshewillbeabletoattend.2. Returntoclinicin2‐3weeksforrecheck3. SchedulePFTs4. IfunimprovedwithmoreconsistentuseofAdvair,mayneedtochangeMDIsORadd
oralmonteleukast.5. DueforPneumovaxatnextvisit.ConsiderDEXA.6. Willconsidernutritionreferral.
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Storyboard
Micah is a 16 year old with a long history of asthma. He had had no prior intubations but 3 ER visits in the past year and 5 courses of oral steroids. He presents to the ED with increasing wheezing and dyspnea since this morning with accompanying cough and rhinorrhea. He used his inhaler (although possibly the wrong one) multiple times during the school day and with only temporary improvement. On his way home from school he began to feel much worse and now presents for evaluation. He is immediately triaged back to a room and placed on 2 liters of oxygen. The ED team (2 residents – one identified in advance as a team leader, 2 nurses, and the Ed pharmacist) walk into the room to assume his care.
Harvey is in hospital bed: patient with nasal prongs on – O2 running at 2 liters IV pole with infusion set – LR running
Act1:InitialAssessmentinED
HR 122BP 154/62Sat% 94%on2litersRR 28Wt 135
Harveybreathsounds:diffusebilateralwheezesprolongedexpiratory
phase
cardiacexamnl
“Ican’tbreathe”
“Where’smyinhaler?”
“Dude,helpme
“Where’smygrandma–didanyonecallher?”
“CanIhavemoreoxygen?”
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Act2:ClinicalDeterioration
IfteamasksforCPAPorBiPAP,machineshouldbepresentedtothem,butMicahshouldbecomeagitated,reportinghecan’tstandthemachineandinsistenttheytakeitoffhim.
Act3:Intubation:Anesthesiaattending(facultyactor)arrivespromptlyandperformsRSI.Donotneedtodemonstratesteps–simplyannouncethatitisdone.Rmainstemintubation.Breathsoundswilldisappearontheleft.
Rampvitalstothosebelow:HR 130BP 135/85Sat% rampdownto90%RR rampdownto16
shallowTV
Harveybreathsounds:lungswithloudwheezes
“Iamreallyfeelingtired”
“Ican’tkeepbreathinglikethis“
“I’mreallyscared”
“Where’smygrandma,Ineedher”
Rampvitalstothosebelowafterintubation
HR 90BP 85/40Sat% rampdownto90%RR rampdownto16
shallowTV
Harveybreathsounds:nobreathsoundsonleftwheezesonright
XTech:“xraywillbebackinabout5min”
Anesth.Attend:“Iamsurethetubeisfine”
IfMDcontinuestoreportRmainstemintub,anesthpullstube back
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IfteammemberinsistsonchangingETTposition,thengotoA
IfteammemberdoesnotinsistonchangingETTposition,thengotoB
A B
WhenXraycomesbackandtubepositioncorrectedgotoAabove
Rampvitalstothosebelowafterintubation
HR rampto110BP 110/70Sat% rampupto99%RR manualvent
Harveybreathsounds:equalbreathsoundsbilateralwheezes
Rampvitalstothosebelowafterintubation
HR rampupto125BP 85/40Sat% rampdownto85%RR manualvent
Harveybreathsounds:nobreathsoundsonleftwheezesonright
XrayTech:“here’syourXray,youbetterlookatit”
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Act4:HandofftoICU–R1inEDtoR1intheICU
Ifpatientnotsedatedforcontinuedintubationgoto
below
Whenpatientsedatedforcontinuedintubationgobacktoabove
Rampvitalstothosebelow:HR 100BP 110/70Sat% 99%on100%BMVRR manualvent
Harveybreathsounds:mildwheezesbilat
Rampvitalstothosebelow:HR ramp145BP 150/795Sat% 99%on100%BMVRR manualvent
Breathsounds:severewheezesbilat
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Act5:Conversationwithgrandparent,whoarrivesinED
Scene:bothR1’sandteamspresent–includingpharmacist
FairlyreasonablegrandmacomesintoEDICU,isquiteupset/worriedthathergrandsonisbeingtransferredtotheICUintubated.
Shehasmanyquestionsaboutwhytheinhalerdidnotpreventthishospitalization.
PharmacistnotedthatMicahwasunclearwhichinhalerhewastouseforacutesymptoms.
Micah’sgrandmotherneedseducationonasthmatreatmentstooptimizetherapy.
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PatientLabsandStudies
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ArterialBloodGas#1
EDAdmission
ph: 7.46
pCO2: 31 torr
pO2: 85 torr
HCO3: 21.0 mmol/L
HCT: 40 %Hgb: 13 g/dL
cNa+ 141 meq/LcK+ 4.9 meq/LcCa2+ 1.08 meq/L
cGlu 110 mg/dL
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ArterialBloodGas#2
AfterintubationFIO21.0
ph: 7.32
pCO2: 50 torr
pO2: 92 torr
HCO3: 22.0 mmol/L
HCT: 39 %Hgb: 13 g/dL
cNa+ 138 meq/LcK+ 4.5 meq/LcCa2+ 1.08 meq/L
cGlu 105 mg/dL
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ArterialBloodGas#3
AfteradjustmentofETtubetocorrectRmainstemintubation
ph: 7.4
pCO2: 37 torr
pO2: 365 torr
HCO3: 24.0 mmol/L
HCT: 39 %Hgb: 13 g/dL
cNa+ 138 meq/LcK+ 4.5 meq/LcCa2+ 1.08 meq/L
cGlu 105 mg/dL