571CHAPTER 48

Interprofessional Team Simulation: Pediatric Rapid Sequence Intubation in Respiratory Failure Due to Severe Bronchiolitis

Jeff Bishop, Maureen M. Ryan, Melissa Holland, and Emma Carrick

A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA

Life-threatening presentations and critical events do not occur with high frequency in pediatric hospital units. One such high-stake event is emergency intubation of children. To develop individual competence, it is estimated that learners need to participate in 20 to 30 of these procedures to obtain competence (Bernhard, Mohr, Weigand, Martin, & Walther, 2012; Kusel, Farina, & Aldous, 2014). Victoria General Hospital (VGH) serves as the regional referral site for pediatrics and 11,000 pediatric patients come through the emergency department, 2,000 of whom are admitted to our pediatric ward and intensive care unit per year (ChildHealth BC, 2014). Within this patient population, we perform pediatric intubation an estimated 25 to 30 times per year outside of the operating room. This mirrors the low rate of pediatric intubation across pediatric units in North America (Nishisaki et al., 2011). VGH is also a regional training center for physicians, nurses, and respiratory therapists. Many of the graduates complete their training and then work in smaller rural centers where the frequency of pediatric intubations is even lower than in the urban hospitals. Thus, the expectation that health professional practitioners obtain and maintain competence during prelicensure training in this critical procedure through clinical exposure is not reasonable. However, simulation-learning events provide a venue by which prelicensure and licensed health care practitioners can learn and practice pediatric intubation without compromising patient safety. Indeed, simulating this necessary clinical learning has been shown to be equivalent to the intensive patient-based learning when measuring individual skill acquisition (Hall et al., 2005).

Here at the Island Medical Program of the University of British Columbia, we have opted to use a scenario of respiratory failure due to bronchiolitis as the basis for leveled simulation learning. Our prelicensure learners encounter the scenario during their preclinical and clinical training in the simulation lab and during postgraduate training, either in the simulation lab or during an in situ simulation on the pediatric ward.

This chapter focuses on the experience of undergraduate nurses, physicians, and respiratory therapy students who are seeing the scenario for the first time in a team environment: interprofessional education (IPE).

572B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY

In advance of the simulation, learners are provided with the detailed case outline, medication lists, and evaluation checklists that preceptors use when teaching. We use a flipped learning model (Betihavas, Bridgman, Kornhaber, & Cross, 2016) and Table 48.1 outlines the required and optional resources to be reviewed before attending the simulation session.

Learner Preparation

Presimulation learning material:

1.  OpenPediatrics module on recognizing respiratory distress (16-minute duration):

     www.openpediatrics.org/assets/video/recognizing-respiratory-distress (Kleinman, 2013)

2.  OpenPediatrics scenario of a patient with bronchiolitis requiring intubation (12-minute duration): www.openpediatrics.org/assets/video/common-intubation-scenarios-bronchiolitis (Wolbrink, 2015). Note that the choice of induction agents (propofol) is different from our suggested agent (ketamine).

C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM

Interprofessional team simulation provides a safe and effective context to practice prelicensure health professional student collaborative teamwork around a patient care event that they will encounter in future as a health care professional. Experiential learning theory guides clinical practice coursework across curricula. Each health professional student licensure competencies cite competency in interprofessional patient care and teamwork. For example, nursing students must meet the standards of practice of interdisciplinary competency outlined by the College of Registered of Nurses British Columbia (CRNBC) Standard 3: Client-Focused Provision of Service (CRNBC, 2013) during clinical courses before their licensure examination (NCLEX). Similarly, medical students must meet competencies as described by the Medical Council of Canada to meet their professional licensing objectives (Licentiate of the Medical Council of Canada Exam [LMCC] part I).

We have learned that students who wish to engage in the interprofessional patient simulations must be able to clearly articulate their roles and have the psychomotor skills requisite to perform their role during the simulation as indicated by the International Nursing Association for Clinical Simulation and Learning (INACSL) Standard VIII: Simulation-Enhanced Interprofessional Education (Sim-IPE; Decker et al., 2015) of the INACSL Standards of Best Practice.

The scenario may be our students’ first exposure to a child in respiratory failure and/or is the first time they have been involved in a simulated intubation of a child. We know that one of the major contributors to errors during rapid sequence induction (RSI) is a result of problematic communication or team functioning (Nishisaki et al., 2011). Thus we remove the cognitive load associated with diagnosis and management planning for our novice teams by providing the full case scenario details to them before the simulation session. Formally structuring the simulation and providing learners with the foreknowledge of the required steps helps ensure that the simulation proceeds with a systematic interprofessional team working toward the expected goals.

D. INTRODUCTION OF SCENARIO

Setting the Scene and Technology Used

Learners arrive in the simulation space and are introduced to each other and the preceptors present. Sessions take place in a simulation lab or in situ using a high- or moderate-fidelity human patient simulator (HPS) and large video screen for displaying laboratory results, radiology images, and other supplemental materials, including a video of, pediatric patients with respiratory distress. All equipment required for the scenario is laid out in advance with the appropriate sizes preselected for the learners.

Table 48.1   Medication Chart

IV, intravenous; q every.

Prebriefing

We begin with introductions of team members and the roles and expectations of all participants. We review the setting, resources available, and the objectives of the session and emphasize the safe nature of the learning environment as a place where mistakes are welcomed as learning opportunities.

Objectives

The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework outlines competencies required for effective interprofessional collaboration within six domains: (a) role clarification; (b) team functioning; (c) patient-/ client-/ family-/ community-centered care; (d) collaborative leadership; (e) interprofessional communication; and (f) interprofessional conflict resolution (CIHC, 2010). For our novice learners, we focus on role clarification, team functioning, collaborative leadership, and interprofessional communication domains as an introductory first level during the simulation and debriefing. Mutually beneficial learning objectives across prelicensure curricula include a practice opportunity to:

1.  Gain knowledge and practice about their role and other health team members when responding to respiratory distress and implementing RSI.

2.  Understand the principles of teamwork dynamics and group/team processes to enable effective interprofessional collaboration and shared decision making.

3.  Share decision making and leadership and accountability for actions, responsibilities, and roles as defined within the professional scope of practice.

4.  Communicate with each other in a collaborative, responsive, and responsible manner.

Description of Participants

We limit the care team to a maximum of five learners, including at least one nursing learner, one physician learner, and, when available, a respiratory therapy learner in his or her senior year of training at the undergraduate level. Roles are assigned as team leader, recorder, medication preparer, airway support person, and miscellaneous support person (depends on training pathway of the learner). We assign one facilitator to alter HPS parameters and provide supplemental material, such as labs or imaging, as 575requested by the team. The other facilitator is tasked with carefully observing team behavior and leading the debriefing process afterward.

One key point that we have identified is the importance of not asking learners to pretend to be a different professional. We emphasize that as professionals we train for very different jobs and that pretending to be a member of a different profession is not appropriate. When medical students are asked to prepare medications, they are not pretending to be nurses; they are physicians preparing medications. Similarly, if nursing students perform the physical tasks associated with managing an airway, they are notrespiratory therapists but rather nurses whose scope of practice may include tasks associated with airway management. We have found that this distinction of task performance versus role play as a member of a different profession removes what can be a barrier to the suspension of disbelief necessary to run the simulation. It also helps prepare learners for the real-life clinical situation of having to perform tasks normally done by another professional because of lack of resources, as may occur in small centers with limited staffing.

E. RUNNING OF THE SCENARIO

After the orientation to space and equipment is completed, learners are presented with a video of a child in severe respiratory distress. They are asked as a group to identify the clinical features observed, including increased work of breathing, as demonstrated by tachypnea, indrawing, tracheal tug, nasal flaring, grunting, and see-saw breathing. The Pediatric Assessment Triangle is used to highlight that the child is in severe respiratory distress with a moderately altered mental status and prolonged capillary refill (Dieckmann, Brownstein, & Gausche-Hill, 2010) The absence of stridor is noted as a learning point that this is more likely a case of lower respiratory tract illness than upper tract pathology. Once the video has been reviewed, learners are assigned their specific roles and are provided a few minutes to meet as a team to discuss their strategy and approach to the patient. The scenario then begins as the team begins to interact with the HPS.

F. PRESENTATION OF COMPLETED TEMPLATE

Title

Pediatric RSI in Respiratory Failure Due to Severe Bronchiolitis

Scenario Level

Prelicensure health professional students

Focus Area

Pediatric acute care hospital setting: Emergency admission of a 4-month-old in respiratory distress

Scenario Objectives

All Learners

•  Describe and identify clinical signs of respiratory distress.

•  Describe and identify clinical and laboratory signs of respiratory failure.

•  Identify and treat oxygenation difficulties.

•  Identify and treat ventilation difficulties.

•  Describe features of lower respiratory tract illness versus upper respiratory tract illness.

•  Administer oxygen therapy.

•  Identify apnea and intervene with one’s scope of practice.

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