419CHAPTER 36
Critical Care/Adult Gerontology Acute Care Nurse Practitioner: Aortic Emergencies
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
The critical care environment is often a difficult and challenging arena in which to provide clinical experiences managing unstable patients for nurse practitioner (NP) students pursuing adult gerontology acute care NP (AGACNP) certification. In most tertiary-level academic critical care centers, students are typically not given the opportunity to independently manage the most unstable critical care patients. Although this may be frustrating for students, this is understandable given the high morbidity and mortality associated with these types of patient encounters. Following graduation, however, many AGACNP students go on to practice in critical care environments where the management of highly unstable patients is commonplace. With this well-documented fact, it becomes necessary for the AGACNP student to become familiar with these types of high-acuity patient care issues before their entry into independent practice. One approach to educating the AGACNP students is to provide them with multiple opportunities to provide care for unstable patients in a high-fidelity human patient simulator (HPS) setting. A simulation curriculum focusing on the independent management of the simulated unstable patient, when paired with clinical rotations in which students are actively managing unstable patients as part of a multidisciplinary team, not only provides the AGACNP student with a diverse learning environment, but also the opportunity to practice what is learned from a clinical practice site in a simulation setting.
When used in conjunction with didactic and clinical curricula, simulation provides unique experiences to improve students’ cognitive and psychomotor skills. Ideally, simulation scenarios should focus on a variety of critical care student-specific cognitive outcomes, including distributed cognition, rapid pattern recognition, situational awareness, and cognitive flexibility. Care should be taken when developing critical care simulations to develop both cognitive and clinical objectives for each scenario. In particular, when simulation is used multiple times throughout an NP curriculum, a consistent focus on diagnostics and interventions should provide the foundation throughout the various individual simulations.
Ideally, each single simulation should be constructed to become part of a series of simulations that complement the students’ didactic and clinical curriculum. For example, students receive didactic content on ventilator management, including diagnostics and interventions for adult respiratory distress syndrome (ARDS), during their critical care didactic. However, in the critical care clinical rotation it may be that a student would not have the opportunity to manage a patient with ARDS either with the clinical team or independently. A simulated scenario allows students to independently diagnose ARDS (using appropriate diagnostic tools), initiate the appropriate therapeutic interventions, and manage any complications that arise. These simulated learning 420sessions provide an opportunity for students to independently care for a complex ARDS patient in a risk-free environment while combining knowledge learned in previous didactic and clinical learning sessions. Once the student has mastered this material, further simulation scenarios can expand on ARDS management in patients with more complex comorbidities.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The Oregon Health and Science University (OHSU) School of Nursing offers a unique AGACNP intensivist program. Its mission is to train AGACNPs for clinical practice in acute care multidisciplinary facilities. AGACNPs specializing in the care of unstable, critically ill patients represent a unique subspecialty of NPs who are routinely required to make highly critical, time-dependent clinical decisions. The overall educational focus for students is in developing cognitive skills that allow for rapid diagnostics and clinical interventions. The AGACNP simulation curriculum revolves around the development of physical and cognitive skills necessary for practice in an acute care environment, including the intensive care unit.
The Collaborative Life Science Building (CLSB) at OHSU was built intentionally to stimulate learning and research across a wide variety of learners. The facility mixes learners and researchers across a variety of health science-related professions. Included in this facility is the 20,000-square foot Simulation Center, which houses the main medical simulation center for the university. This facility contains eight state-of-the-art high-fidelity simulation suites with the ability to be reconfigured into a variety of medical settings, including hospital medical–surgical rooms, operating rooms, emergency department (ED) rooms, ICU suites, a postanesthesia recovery room, and medical consultation rooms. Along with the simulation suites, there are two multipurpose classrooms, seven debriefing suites, eight bed-skills training labs, and 20 clinic rooms for use with standardized patients.
Each simulation suite has separate audio and visual capabilities that allow for projection and recording throughout the CLSB. The separate control rooms, each adjoining a corresponding simulation suite, allow for faculty and a simulation engineer to observe students behind a one-way mirror and to adjust the simulation content depending on student progress. With the size of the room, it is possible to simulate more than one ICU scenario at a time if the faculty wishes to create concurrent scenarios in which multiple complex problems need to be addressed simultaneously. These scenarios allow students to use HPSs as surrogates for live patients while providing a real-world feel to practicing in the ICU. The HPSs are equipped to mimic patients with simulated heartbeats, respirations, bowel sounds, pulses, and the ability to converse with students as the simulation session warrants. In addition to the HPS, critical care monitors display all of the physiologic data typically found in the ICU, and radiographic monitors display tests ordered by students during the simulation. Working ventilators are used for simulations requiring ventilation management. Simulated activities and interactions can be digitally recorded and archived for use by faculty and students to enhance learning.
Partial task trainers are used to provide introductory procedural training, including airway management, arterial line placement, central line placement, chest decompression, and chest tube placement. These skills are then integrated into larger clinical simulations focusing on complex diagnostic reasoning and intervention. Once students are able to master these clinically focused sessions, simulations incorporate trained actors or faculty to expand the scenarios to include patient/family issues and conflict resolution among medical team members. The addition of these situational factors provides students the opportunity to develop interpersonal skills necessary for ICU practice, such as rapid consultation, family and patient interactions, and delivering difficult news to families.
AGACNP faculty are all certified in medical simulation instruction through the Harvard Center for Medical Simulation. This ensures consistency among the faculty regarding the overall approach to objectives, outcomes, and debriefing styles. This is particularly important when 421simulation is repetitively used, as it provides a consistent educational approach and ensures student outcomes align from simulation to simulation.
C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
This scenario is designed as part of a year-long simulation course that runs concurrently with the AGACNP clinical rotations within our academic tertiary-critical care unit. This simulation is considered moderately difficult in the program, as it requires rapid diagnostics and interventions, critical care team interaction, strong medical differential diagnostic skills, the ability to perform rapid sequence intubation, ventilation management, and time-dependent communication with consultative services. This simulation would occur midway through the AGACNP program. All students in the scenario would have had clinical student responsibilities on a critical care team for at least 6 weeks and would have undergone a radiology, advanced airway and ventilator workshop before the simulation.
Student Learning Activities
• Differential diagnosis with identification of primary diagnosis
• Rapid evidence-based interventions
• Identification of the definitive treatment for aortic rupture
• Review of aortic dissection treatment
• Review of aortic rupture treatment
• Review of transfusion strategies for exsanguination
D. INTRODUCTION OF SCENARIO
Setting the Scene
The setting is an ICU hospital room in a tertiary-level medical center. Students are on a critical care team consisting of no more than six students. The provider team has been called to the bedside by the ICU nurse for a new admission, who has just arrived from an outside hospital (OSH) via an emergency service helicopter.
Technology Used
The high-fidelity HPS is a male, running manually, with the following vital signs: heart rate (HR): 116 beats/minute, blood pressure (BP): 128/77 mmHg, pulse oximetry: 100% on 2 L/minute per nasal cannula, respiratory rate (RR): 29 breaths/minute. The HPS has been hooked to basic telemetry, automatic sphygmomanometer (q [every] 15 minutes), and pulse oximetry. The patient has an 18-gauge intravenous (IV) catheter placed at the right antecubital fossa. There is an IV infusion of nitroglycerine running through 25 µg/minute. The HPS is identified by the bedside ICU nurse as “David Johnson” and is dressed in a hospital gown. Stethoscopes, gloves, an airway cart containing intubation equipment, airway adjuncts, a ventilator, and a code cart stocked with advanced cardiac life support (ACLS) medications and medications for rapid sequence intubation (RSI) are available for student use. A screen appropriate to reading radiographs is available for viewing chest x-rays (CXRs) and CT scans. Medications available include IV fluids, inotropes, vasopressors, packed red blood cells, and fresh frozen plasma and platelets. A telephone system is connected to the simulation control center, allowing students the option of “calling” a consultant. A microphone system is connected to the HPS, so it may respond to questions asked by the students.
422Objectives
1. Identification of critical care team leader with appropriate distribution of duties among the team
2. Appropriate history and physical examination
3. Differential diagnosis of chest pain (must include aortic dissection/rupture)
4. Appropriate interpretation of chest radiograph
5. Appropriate ordering of CT scan
6. Diagnosis of acute respiratory failure
7. Appropriate airway management with rapid sequence intubation
8. Diagnosis of aortic dissection
9. Appropriate treatment of aortic dissection
10. Diagnosis of aortic rupture
11. Appropriate treatment of aortic rupture
12. Appropriate consultation with vascular surgeon for emergent surgical intervention
Description of Participants
HPS: Mr. Johnson is a 58-year-old gentleman who just arrived from an OSH to be admitted to the ICU. He was seen at the OSH’s ED for crushing chest pain and shortness of breath. He has a past medical history (PMH) of hyperlipidemia, arthritis, and prostate hypertrophy. His initial EKG was nonspecific for ischemia and his troponin was negative, but he continued to have significant chest pain. His CXR from an OSH is available and noted to be “mildly abnormal.” His pain was treated with as needed (PRN) IV morphine, a nitroglycerin infusion, a single oral dose of aspirin, and oxygen by nasal cannula. He was sent to the ICU for further workup.
AGACNP student critical care team: This team consists of two to six AGACNP students currently training in critical care. A maximum of six students can participate in this scenario. Students should be familiar with the formation of a critical care team for dealing with critically ill patient situations. Ideally, these students have already had critical care team training, airway management, and ventilator management education before participating in this scenario.
Bedside ICU nurse: The bedside nurse is a confederate within the simulation and is available to assist the student team. Ideally, the role of bedside nurse is played by an RN, trained specifically for simulation, teaching, or a simulation engineer trained for the role and has a wireless ear microphone connected to the engineer/faculty within the control room. The bedside nurse is instructed to provide labs or other clinical data as needed throughout the scenario.
Vascular surgery consultant: The vascular surgeon is a confederate within the simulation and should be used for consultation. The surgeon will be available for phone consultation and will be willing to see the patient only when students have identified the correct diagnosis (i.e., thoracic aortic rupture) and recommend emergent operation.
E. RUNNING OF THE SCENARIO: PREBRIEFING
Students should be briefed before the simulation with information regarding the simulation setup in general (room, HPS, phone system, etc.), and given adequate instruction to the clinical resources available. In general, we instruct students to assume that they are at an academic medical center with all diagnostic and clinical resources available to them during the simulation.
Before the initiation of the simulation, students are brought to the simulator suite and are read the patient history before entry into the room. They are then introduced to the bedside nurse, and any logistic or HPS-specific questions are answered.
423F. PRESENTATION OF COMPLETED TEMPLATE
Title
Critical Care: Aortic Emergencies
Scenario Level
Graduate-level (AGACNP) or doctoral-level critical care specialization master’s level AGACNP students (intensivist subspecialty focus)
Focus Area
Intensive care/critical care
Scenario Description
Mr. Johnson is a 58-year-old gentleman who just arrived from an OSH to be admitted to the ICU. He was seen at the OSH’s ED for crushing chest pain and shortness of breath. He has a PMH of hyperlipidemia, arthritis, and prostate hypertrophy. His initial EKG was nonspecific for ischemic and his troponin was negative, but he continued to have significant chest pain. His CXR from OSH is available and noted to be “mildly abnormal.” His pain was treated with IV morphine, a nitroglycerin infusion, a single oral dose of aspirin, and oxygen by nasal cannula. He is sent to the ICU for further workup.
Past Medical History
Gastroesophageal reflux disease
Hypertension
Hyperlipidemia
Obesity
Migraine headaches
Past surgical history
None
Social History
Marital history: Married
Education: Completed college degree
Employment: Office manager in local business
Denies smoking and illicit drug use
Home Medications
Aspirin 81 mg daily
Lovastatin 20 mg hs (at bedtime)
Lisinopril 20 mg daily
Pepcid 20 mg BID (twice a day)
Allergies
No known drug allergies
424Scenario Objectives
1. Identification of critical care team leader with appropriate distribution of duties among the team
2. Appropriate history and physical examination
3. Differential diagnosis of chest pain (must include aortic dissection/rupture)
4. Appropriate interpretation of chest radiograph
5. Appropriate ordering of CT scan
6. Diagnosis of acute respiratory failure
7. Appropriate airway management with rapid sequence intubation
8. Diagnosis of aortic dissection
9. Appropriate treatment of aortic dissection
10. Diagnosis of aortic rupture
11. Appropriate treatment of aortic rupture
12. Appropriate consultation of vascular surgery with recommendation made for emergent surgical intervention
These simulation objectives meet several of the overarching objectives noted within the American Association of Colleges of Nursing’s (AACN, 2011) Essentials of Master’s Education in Nursing. The scenario requires the student to perform two of the core competencies including:
Essential IX: Master’s-Level Nursing Practice, Objectives 1, 2, 7
These objectives meet the following overarching objectives noted within AACN’s (2006) Essentials of Doctoral Education for Advanced Nursing Practice:
Essential VII: Advanced Nursing Practice, Objectives 1, 2
Setting the Scene
Equipment Needed
High-fidelity HPS, video-recording device, medical equipment (e.g., patient monitor, oxygen hookup, airway management equipment, ventilator, pulse oximeter, BP cuff, and stethoscope), and medical record (electronic or paper)
Resources Needed
Contrast chest CT images revealing descending thoracic aortic rupture; students should have had basic airway management (including rapid sequence intubation techniques) and introduction to radiographic imaging before simulation
Simulator nevel
High-fidelity
Participants Needed
AGACNP student critical care team (typically five to six students): This team is formed of AGACNP students currently training in critical care. A maximum of six students can participate in this scenario. Students should be familiar with the formation of a critical care team for dealing with critically ill patient situations. Ideally, these students have already had critical care team training, airway management, and ventilator management education before participating in this scenario.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
