163CHAPTER 16
The Use of Simulation in the Recognition and Response of the Rapidly Deteriorating Patient
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
As simulation continues to gain traction in the preparation of undergraduate nursing students, specific strategies are being developed to enhance performance in the practice area. One such strategy includes a comprehensive high-fidelity simulation (HFS) intervention that is aimed at improving recognition and response to the rapidly deteriorating patient. The intervention includes pediatric- and adult-based acute care scenarios. Students are exposed to a hybrid approach to simulation through opportunities to complete both high-fidelity and virtual simulation cases. The simulation cases were developed and tested using best practices in simulation that included the International Nursing Association for Clinical Simulation and Learning (INACSL) Simulation Standard IX: Simulation design (Lioce et al., 2015), content expert panels, the use of peer-reviewed simulation case templates (Goldsworthy & Graham, 2013) and a “dry run” with subsequent refinement of all cases. Prebriefing of students was completed through required pre-readings, an overview of the learning objectives, and an orientation to the simulation learning space. In addition to the preparation of the students, the instructional team was also prebriefed by reviewing and running all of the cases, the evaluation tools, and participating in a dry run and setup of all learning stations.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The simulation intervention was completed in the simulation lab at the Faculty of Nursing, University of Calgary. The simulation lab has three simulation suites, three debriefing rooms, and a control room. High-fidelity human patient simulators (HFHPSs) were used for all six cases. The HFHPSs used in this initiative consisted of three adult HPSs, two pediatric HPSs, and one infant HPS. Every effort was made to closely mimic the actual practice environment and included such equipment as a baby warmer, blood bank, simulated urine, simulated blood, intravenous (IV) lines or saline locks, airway management equipment, defibrillators, crash cart, cardiac monitors, realistic dressings, and moulage as appropriate. In addition, each bedside had a patient chart, lab values, doctor’s orders, and flow sheets for assessments and vital sign documentation. Examples of equipment to stage the scenario are described in an overview “recipe” card template (see example in Table 16.1).
Table 16.1 Simulation Overview Recipe Card
Learning objectives | The student will: 1. Perform a focused cardiac assessment based on the patient’s presentation. 2. Recognize normal and abnormal assessment findings. 3. Identify patient’s worsening condition and notify with info to physician. 4. Prioritize interventions based on findings and assessments. 5. Document assessment findings. 6. Administer medications accurately identifying indications, contraindications, and associated side effects. 7. Accurately interpret any results and note abnormal lab values. 8. Demonstrate advanced communication skills with a patient experiencing chest pain. |
Equipment needed | Saline lock for right hand, nasal prongs, nitroglycerine, O2 saturation machine, HFHPS, role name tags, clipboard for lab values, doctor’s orders, vital sign flow sheet, IV pump, emergency equipment, resuscitation bag, oral airway, crash cart, identification band for patient, urinal, suction equipment and flow meter, scenario and script, pretest/posttest, debriefing questions, blood pressure cuff, thermometer. |
Introduction | Administer pretest Mr. Dressup, a 54-year-old patient, is admitted to the medical floor with a diagnosis of R/O MI (rule out acute myocardial infarction). He has a history of hypertension and one previous MI. |
Body of Scenario | Patient develops chest pain while initial assessment is taking place. His condition worsens after two sprays of nitro; he becomes unresponsive and goes into cardiac arrest. |
Conclusion | Scenario ends while CPR is in progress and after code blue has been called. |
Debriefing | Administer posttest see debriefing questions |
CPR, cardiopulmonary resuscitation; HFHPS, high-fidelity human patient simulators; IV, intravenous; MI, myocardial infarction.
C. SPECIFIC OBJECTIVE FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Programmatic Level of Scenario: Prelicensure
The goal of the recognition and response to a deteriorating patient educational intervention was to strengthen our final year (term 7) baccalaureate nursing students’ performance in reacting to and intervening appropriately in a timely manner to a change in patient condition.
D. INTRODUCTION OF SCENARIO
The setting for the scenarios in the deteriorating patient cases was an acute medical–surgical unit. A combination or hybrid approach of HFS and virtual simulation cases was used. Students completed 16 hours of HFS over 2 days. The high-fidelity cases were completed over 2 weeks (8 hours/day). In addition, all students were asked to complete one virtual pediatric case scenario and one virtual adult scenario during the HFS days. The technology used was the VSim® for Nursing: Medical–Surgical program (Wolters Kluwer/SLN/Laerdal, 2015).
165E. RUNNING OF THE SCENARIO
Deteriorating Patient: High-Fidelity-Scenario Approach
Each high-fidelity scenario was run over 1 hour. Figure 16.1 shows the breakdown of the simulation case timing. The prebriefing period was 15 minutes in duration and included an orientation to the simulation space, HPS, role assignment, handover report, and pretest questions that were completed individually.
Each student was assigned a role and worked on the case in teams of four. Roles included primary nurse, secondary nurse, lab/diagnostician and a pharmacology role. The intent was that the primary and secondary nurse completed the initial assessment at the head of the bed and the lab/diagnostics and pharmacology students worked at the foot of the bed reviewing lab and diagnostic results and doctor’s orders and communicated this information to the students completing the assessments. Each case was repeated on the second day of the HFS to allow for increased mastery of the acute care medical–surgical (adult and pediatric) competencies. High-fidelity cases included angina/cardiac arrest, chronic obstructive pulmonary disease (COPD)/respiratory failure, postoperative hemorrhage, pediatric sepsis, pediatric asthma, and neonatal seizures (Figure 16.2).
Figure 16.1 Timing of high-fidelity simulation delivery.
Figure 16.2 High-fidelity simulation scenario of a deteriorating patient.
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Figure 16.3 Virtual simulation.
Deteriorating Patient: Virtual Case-Scenario Approach
In the virtual cases, students can repeat the cases as many times as they want to achieve mastery with the case. The virtual cases included an electronic preparation guide to orientate students to the program and technology before beginning the case. Each case also had suggested readings and pretest questions and answers to further prepare the student before entering each of the virtual cases. The virtual simulation program used allowed students to “drive” the scenario and end the scenario when they felt they had completed the needed assessments and interventions. At the conclusion of the case, the student was provided with a pretest, guided reflection questions, and a debriefing log outlining a sample screen of the virtual simulation case and how the student performed in the case, as shown in Figure 16.3. The debriefing log also included comprehensive rationales for incorrect interventions and choices.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Deteriorating Patient Simulation (University of Calgary Case 2.0: Myocardial Infarction [MI])
Scenario Level
___Baccalaureate level (bachelor of science in nursing [BScN])
Focus Area and Scenario Description
Scenario purpose: To teach nursing management of the patient experiencing myocardial infarction in the medical/surgical practice setting.
Scenario number: 2.0
Scenario focus: MI/cardiac arrest
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