- Email: [email protected]
Interprofessional Education: A Multi-patient, Team-Based Intensive Care Unit Simulation
Clinical Simulation in Nursing (2014) 10, 521-528
www.elsevier.com/locate/ecsn
Featured Article
Interprofessional Education: A Multi-patient, Team-Based Intensive Care Unit Simulation Penni Watts, MSN, RN, CHSEa,*, Summer B. Langston, DNP, CRNP, ACNP-BCb, Michelle Brown, MS, MLSc, Charlie Prince, BAd, April Belle, MSN, RNe, Mark Wayne Skipper, BAf, Jerry P. King Jr., RRT, MAEdg, Jacqueline Moss, PhD, RN, FAANh a
Director of Clinical Simulation/Instructor, UAB School of Nursing, Birmingham, AL 35294-1210, USA Assistant Professor, UAB School of Nursing, Birmingham, AL 35294-1210, USA c Assistant Professor, UAB Department of Clinical and Diagnostic Sciences, Birmingham, AL 35294-1210, USA d System Administrator, UAB Office of Interprofessional Simulation for Innovative Clinical Practice, Birmingham, AL 35249-5980, USA e Simulation Coordinator, UAB Hospital, Birmingham, AL 35249-5980, USA f Clinical Simulation Specialist, UAB Office of Interprofessional Simulation, Birmingham, AL 35249-5980 USA g Interim Program Director/Assistant Professor, UAB School of Health Professions, Birmingham, AL 35294-1210 USA h Professor and Chair, UAB School of Nursing, Birmingham, AL 35294-1210, USA b
KEYWORDS interprofessional simulation; clinical laboratory science students; respiratory therapy students; medical residents; nursing students
Abstract: In this article, we describe a multi-patient, team-based simulation experience in an academic setting. We included participants from clinical laboratory science, respiratory therapy, nursing, and medical residents. This simulation allowed students to function as credentialed professionals, focusing on critical thinking, prioritization, effective communication, and teamwork. In order to fully incorporate all professions, we designed an extended-time simulation in which we strategically planned the sequencing of clinical events in each scenario. Because of the complexity of the scenarios, debriefing progressed through three levels: in-room, whole group, and profession specific. Although designing and implementing such a detailed simulation was challenging, we feel it is essential to prioritize teamwork and communication in the academic setting. Cite this article: Watts, P., Langston, S. B., Brown, M., Prince, C., Belle, A., Skipper, M. W., King, J. P., & Moss, J. (2014, October). Interprofessional education: A multi-patient, team-based intensive care unit simulation. Clinical Simulation in Nursing, 10(10), 521-528. http://dx.doi.org/10.1016/j.ecns.2014.05.004. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Delivery of patient-centered care is dependent on a team or network of individuals working together to achieve common patient goals. Such care requires a variety of team
* Corresponding author: [email protected] (P. Watts).
members, including the patient, to have equitable opportunity for input into decision making and communication to produce quality outcomes (World Health Organization, 2011). Patient-centered, team-based care has proven to be an effective, safe approach to care provision. The practice census, a survey of current cardiovascular practices
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.05.004
Interprofessional Education
522
conducted by the American College of Cardiology, found that those operating in team-based settings had increased efficiency (63%), improved quality of care (53%), increased patient satisfaction (50%), and increased staff satisfaction (36%). These teams were also more likely to implement patient education (69%) and internal Key Points communications (63%) as Simulated complex part of standard care protoclinical situations imcols (Brindis, Rodgers, & prove team commHandberg, 2011). unication. Although the move to Creating a realistic ward team-based care is on intensive care unit the rise, accelerating implesimulation offers a mentation of this approach safe environment to will require that students be rehearse team clinical introduced to this concept decision making. early on through educational Strategies are needed programs. The Institute of to support developMedicine makes team-based ment of complex interapproaches to health care a professional simulated priority by encouraging events. funding for demonstrations of interdisciplinary professional education in the Health Resource and Services Administration (Interprofessional Education Collaborative Expert Panel, 2011). Our faculty team sought to develop team training activities through the use of simulation. With a wealth of health professions on our campus, we are able to include multiple professions into a variety of educational experiences. Using simulation for promoting collaboration, teamwork, and improving relationships through team training is an explicit goal of our university. The purpose of this article is to describe a team-based simulation experience involving multiple patient scenarios running simultaneously to prepare students from multiple health care professions to work together to enhance the delivery of effective high quality care and to decrease the potential for error in practice.
Use of Team-Based Simulation One such approach to meeting the need for interprofessional education is through the use of interprofessional simulation. Team-based simulation has been widely used by the military and aviation communities for many years (Salas et al., 2008). Because of its proven success in these areas, this type of training has been applied to patient care and has been shown to improve team skills and employment retention across multiple health care settings (Wayne, Didwania, & Feinglass, 2008). A review of an interprofessional simulation involving nursing students, medical students, and medical residents found that learners perceived simulation-based experiences to be valuable and relevant and that learning in this manner aided in reaching across professional silos
(Baker et al., 2008). In addition, interprofessional simulation in health care education prepares students to more readily enter the clinical setting armed with effective communication and collaboration skills (Robertson & Bandali, 2008; Ulrich & Mancini, 2014).
Institutional Efforts Recognizing the importance of interprofessional education and in keeping in accordance with Institute of Medicine recommendations, the University of Alabama at Birmingham utilizes interprofessional simulation as a tool to introduce students to team-based care in a controlled environment (Ulrich & Mancini, 2014). At the University of Alabama at Birmingham, the Office of Interprofessional Simulation for Innovative Clinical Practice, a universitywide center that brings together staff, faculty, and students, has been established to ensure that goals for interprofessional education are met. The center is comprised of faculty and staff from multiple disciplines who work collaboratively to plan and implement interprofessional simulation activities. Some such activities are weekly simulations that involve students from multiple health professions schools. These simulations take place in our partner health care facility and are part of an ongoing endeavor to continue the integration of simulation into respective health profession curricula. These simulation experiences are often brief, which makes it challenging to focus on all the core competencies outlined by Interprofessional Education Collaborative (IPEC) (Interprofessional Education Collaborative Expert Panel, 2011). Table 1 summarizes the IPEC competencies. Because of the time constraints of the brief weekly multiprofessional simulations, a group of interdisciplinary faculty sought to use the IPEC competencies as a framework for the development of a multi-patient, multiprofessional, extended simulated session. This extended simulation session would aid in reinforcing the core competencies for the clinical laboratory science (CLS), medicine, nursing, and respiratory therapy students that participated in the weekly interprofessional simulations. These competencies were built into the heart of the extended simulation, which was designed to challenge learners by creating an experience with significant complexity to allow for critical thinking, prioritization, and team-based communication in a critical care setting. As part of our institutional efforts in team training, we have developed learning activities for a variety of students from multiple professions. In this learning activity with real-time simulation, we were able to include laboratory science students to simulate specimen analysis in a compressed time frame. Involving laboratory students is a novel way to improve collaboration and communication in clinical practice. There are few publications documenting the involvement of the clinical laboratory in interprofessional
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Interprofessional Education Collaborative Core Competencies
Core Competency
Basic Principles
Value/ethics for interprofessional practice Roles/responsibilities Interprofessional communication Teams/teamwork
Mutually respectful relationships; professions add insight; and diversity Acknowledges team complexity and role clarification Essential for safe care and streamlined approach Patient-centered goals and shared expertise
Source: Interprofessional Education Collaborative Expert Panel, 2011.
simulation experiences. In a report from the Mayo Clinic Department of Laboratory Medicine it was noted that the clinical laboratory provides data that influence 60% to 70% of clinical decisions (Forsman, 2002). Enhancing communication between the laboratory and clinical staff directly improves patient safety (Katz et al., 2013).
volunteer participants. This interprofessional multi-patient simulation was designed to mimic an afternoon in the intensive care unit (ICU) to provide a realistic exercise in critical thinking, dynamic prioritization, effective communication, and teamwork.
Scenarios
Overview of the Simulation This simulation experience was designed to use an interactive scenario to encourage students to prioritize patient care and communicate effectively with other members of the health care team to offer safe, quality health care. Four scenarios, run simultaneously over 90 minutes, provided challenges for two second-year medical residents, eight nursing students, three respiratory therapy students, and three CLS students. Student participation at the event was required by some program faculty as part of a specific course while other students were
Table 2
Four simulated ICU patient cases were developed that included a range of common medical ICU conditions. Two of the simulated patients were recent admissions; and one patient had resided in the ICU for 2 weeks. The fourth patient was admitted from the emergency department during the simulation. An overview of the scenarios can be found in Table 2. Each patient had a planned progression of events, which would occur during the extended simulation. Timing the events in the simulation played an integral part in providing an opportunity for the participants to prioritize care according to the available resources. The outcomes of the patients were a direct result of the care
Scenario Summary
Case
Diagnoses
Presentation
Outcome
Lewis Upper gastrointestinal bleed Abernathy with liver failure and blood transfusion reaction transfusion-related acute lung injury (TRALI) Gayle Sepsis, suspected pulmonary Redmond embolism, and pulseless electrical activity (PEA) arrest
Severe hypotension Needs consent for blood, central venous line, arterial line, esophagogastroduodenoscopy
Respiratory distress Blood transfusion reaction Requires endotracheal intubation
Admitted from nursing home Slight respiratory distress Requires high-flow nasal cannula and computed tomography angiography of the chest
Norman Bradshaw
Chronic obstructive pulmonary disease exacerbation
Newly admitted from the emergency room Respiratory distress
Diego Sanchez
Pneumonia, ventilator weaning, and medical equipment troubleshooting
Critical laboratory values: blood glucose ¼ 25 and serum potassium ¼ 2.3 PEA arrest Requires cardiopulmonary resuscitation, endotracheal intubation, and central venous line placement Requires positive pressure ventilation Refuses endotracheal intubation Accepts noninvasive positive pressure ventilation Code statusddo not resuscitate Cuff leak develops Endotracheal tube changed Vent weaning continued as ordered
Admitted 12 days ago with pneumonia Intubated 10 days ago Failed vent wean 5 days ago Ready to wean and weaning in progress
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Simulation Timeline
Case
Facilitators
1345
Lewis Computer operator, Abernathy voice, ESP, and family member
Gayle Redmond
Computer operator, voice, ESP, and family member
Norman Bradshaw
Computer operator, voice, ESP, and family member
Diego Sanchez
Computer operator, voice, ESP, and family member
Stat laboratory
ESP
Main laboratory
ESP
1430
1500
1510
Prebrief orientation RN shift report: needs second IV HR, 110; BP, 92/47; RR, 25; and O2 sat 95% on 5 L Prebrief orientation RN shift report: needs 20 g IV for CT HR, 95; BP, 95/37; RR, 28; O2 sat 90%; temperature, 101.3 F Prebrief orientation RN shift report: Pt not arrive to unit yet Prebrief orientation RN shift report: Wean from vent HR, 75; BP, 129/72; RR, 18; and O2 sat 99% Rapid hCG received through tube system
MD and RT checkout HR, 132 and BP, 68/37
Responds to fluids Needs consent for blood and CVL Blood ready
MD and RT checkout O2 sat 89%
O2 sat 88%
Prebrief orientation Receive specimens to send to main laboratory Prebrief orientation Analyze prioritized Specimen specimens prioritization Proceed with testing
MD and RT checkout
MD and RT checkout
Rapid Strep test received through tube system
Receive specimens on Redmonddrejected, hemolysis
Analyze prioritized specimens
Notify nurse that blood is ready
Note. ESP ¼ embedded simulation participant.
given during the simulation. There were no planned patient deaths.
Collaboration Platform During the conception and development phase of this ICU simulation, it was necessary to share documents between multiple facilitators across our large institution. To prevent an overwhelming amount of e-mail exchanges, and to prevent multiple concurrent versions of the documents related to this event, we decided it was best to utilize Microsoft SharePoint 2010 to address these issues. SharePoint 2010 is a platform for collaboration, content management, business intelligence, data warehousing, and creating intranets and public-facing websites. The Office of Interprofessional Simulation already had an extensive intranet, so it was easy to partition off some new space to dedicate to this ICU simulation. In this new space, a document library was created that allowed the facilitators of this event to edit the same documents collaboratively, while retaining versions of everyone’s edits. This document library also provided a layer of security, as permissions to
access it were strictly limited to the participating facilitators, thereby requiring authentication with their credentials. Ultimately, SharePoint served its purpose in preventing dozens of versions of the same document from floating around multiple e-mails, as well as serving as a central location to securely store these documents.
Simulation Designing a multi-patient ICU simulation with four professions required extensive planning and scripting. The simulation event manager developed case stems and worked in conjunction with the other professions to fill in appropriate case details ensuring accuracy from each perspective. Because of the complexity of each case and the many moving parts, a timeline was created for organization and sequencing of events during the simulation as shown in Table 3. This timeline was created to provide clear directions for the embedded simulation participants (ESPs), simulation operators, faculty, and staff facilitating the experience. Throughout the 90-minute simulation experience, events such as changes in the patients’ clinical
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(Continued)
1518
1520
Bring pickup slip for red Transfuse packed red cells to stat laboratory blood cells (RBCs) to get blood
Slight distress, O2 sat 87%, high-flow NC up to 94%
1530
1535
Post-transfusion vitals: HR, 130 and BP, 75/42
1545 Acute respiratory distress from transfusion TRALI Intubate pt HR, 132; BP, 73/40; RR, 38; and O2 sat 88%
Back from CT; has PEA arrest; and requires CPR, ETT, and CVL
Receive call from laboratory with critical resultsdglucose and potassium Patient admitted in distress and refuses intubation
Family arrives and code status discussion
O2 sats dropdETT cuff leak HR, 127; BP, 167/72; O2 sat 87%; and RR, 30
Change ETT
Issue packed RBCs to nurse
Rapid flu test
Receive specimens on Abernathydrejected, not labeled correctly
Laboratory call to reject clotted CBC on Abernathy
Analyze prioritized specimens
Call critical result to RNdglucose, 25 mg/ dL and potassium, 2.3 mEq/L
Analyze prioritized specimens
Analyze prioritized specimens
conditions, critical laboratory analysis and results, patient transport, and an emergency patient admission all required students to apply clinical decision-making and teamwork skills. ESPs facilitated the simulation portraying family members, clinicians, a laboratory supervisor, and one as a simulated patient. The simulation took place in the simulation center staged to resemble a four-bed ICU. The experience included a total of four simulated patients; three highfidelity human patient simulators were used to allow students to practice interventions such as intubation, urinary catheter insertion, and chest compressions, whereas one faculty actor was used for realistic interaction and communication regarding end-of-life counseling. Two nursing students were assigned to each patient. They were given a full verbal and written handoff report from an ESP as the off-going nurse, before beginning their shift assessments. The nursing students began the simulation 15 minutes before the medical residents and respiratory therapy students. During this time, the medical residents and respiratory therapy students received a full handoff report. The CLS students were split into two groups, and
one student was assigned to the simulation center along with one faculty member who worked in the simulated onsite clinical laboratory. The other students were located off site across campus with another ESP and communicated with the health care team by phone as they ran laboratory tests in the on-campus simulated clinical laboratory.
Simulation Setup Intensive Care Unit In the simulation laboratory, a total of four simulated patient rooms were utilized. One room was permanently staged to host operating room simulations, the remaining rooms were set up much like conventional intensive care patient rooms with supply cabinets, a stretcher, and a head wall with electrical outlets, air, and oxygen. These rooms housed the three high-fidelity simulators (CAE Healthcare HPS, a Laerdal SimMan 3G, and a Laerdal SimMan Essential) and the one standardized patient. The standardized patient was wheeled into the unit on a stretcher roughly 30 minutes after the simulation had begun, thus
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simulating a new patient admission through the emergency department. An adjacent administrative area was converted to provide counter space for the laboratory to sort samples and make telephone calls. Within the simulation center, two control rooms were used to operate three simulators. While one person controlled a simulator from the operating room’s control room, two more operators and an actor portraying the voice of a patient worked from the main control room. The operators were assisted by the facilitators or circulators who interacted with the learners and reported back to the operators as needed, allowing for those operating the simulators to adjust to the learners’ actions as the cases progressed. Moulage of the manikins was kept to a minimum for this ICU simulation. Each manikin was outfitted with IV lines, a urinary catheter, or other devices as needed to match the patient scenario. Supplies such as IV tubing and fluids, medications, urinary catheters, and general medical supplies were stocked in carts outside each simulation room. Crash carts were stocked and prepared with intubation equipment, a defibrillator, and similar supplies found on standard crash carts in the hospital. Each scenario was accompanied by a full shift report and a medical record complete with an appropriate medical history and physical, a list of home medications, laboratory results, vital signs, intake and output, progress notes, medication administration record, procedure notes, and imaging reports. Participants were encouraged to perform as licensed professionals even if they were students. The students were expected to assess their patients and work together to determine appropriate interventions such as fluid resuscitation, blood administration, medication administration, appropriate oxygen and/or ventilation therapy, laboratory analysis, troubleshooting medical equipment, and cardiopulmonary resuscitation. Clinical Laboratory Two laboratories were prepared and staffed by CLS students and ESPs. One was a ‘‘stat’’ laboratory in the ICU where rapid testing was performed. This also served as a specimen receiving area for laboratories drawn during the simulation. The second laboratory, offering a full array of laboratory diagnostics, was located in the student’s learning laboratory in the CLS building on the University’s campus. Real blood specimens were analyzed and therefore required a biosafety Level 2 laboratory. This also accurately reflects the reality that the laboratory is often not near the ICU, since it serves the entire hospital as well as providing an opportunity for students in the ICU to communicate with students at the laboratory via telephone. Also, having one group of clinical laboratory students off site was part of the simulation design plan to mimic a realistic portrayal of health care facilities in which the laboratory is not always near in proximity, and there may in fact be some delay in the processing of specimens.
In preparation for the scenario, it was necessary to ensure there were samples for the laboratory students to analyze that were not related to the four patients in the simulation. In the real clinical setting, when the laboratory receives a call about a particular patient, the scientist has to sort through potentially hundreds of other patient samples and results to find what the clinician needs. Multiple real human blood specimens for 18 patients were prepared. These specimens were evaluated in multiple disciplines within the laboratory: blood bank, hematology, chemistry, and microbiology. Each laboratory order included a test requisition, specimen, and relevant patient history. There were functioning telephones in the laboratory as well as the ICU simulation area to facilitate communication of results, blood product availability, and specimen acceptability.
Prebriefing The purpose of prebriefing is to communicate to the student that this is a safe learning environment before the simulation experience. Students are given information or preparatory instructions that help the participants achieve the scenario objectives (Meakim et al., 2013). Prebriefing of students occurred before the simulation and involved multiple components including confidentiality, the fiction contract, our basic assumptions, as well as instructions for learners to access data, equipment, and supplies (Meakim et al., 2013). Prebriefing and discussion of the case stem was organized by discipline. CLS students were the first group of students to be briefed 45 minutes before the commencement of the simulation allowing them to begin specimen analysis and to report results at appropriate times throughout the simulation.
Debriefing Debriefing for such a large and complex simulation presented many challenges. All students underwent extensive debriefing on three levels: scenario, simulation, and profession. To accomplish this, debriefing was performed according to the following: in-room (scenario), large conference room (all simulation participants), and disciplinespecific breakout sessions (profession). Immediately after the simulation, students and ESPs remained in their respective rooms for the initial in-room debriefing. Facilitators reviewed case-specific reflection and discussion utilizing the plus and/or delta debriefing technique (Fanning & Gaba, 2007). Following the in-room debriefing, participants gathered in a large conference room for the large group interprofessional debriefing. To address multiple disciplines in the simulation, the majority of the debriefing time was dedicated to discussion of time management, interprofessional communication, and teamwork. This debriefing was facilitated by two lead debriefers with cofacilitators by each student group’s faculty member.
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Structure of this portion of the debriefing was modeled after debriefing with good judgment (Rudolph, Simon, Dufresne, & Raemer, 2006; Ulrich & Mancini, 2014). This debriefing included three phases: reactions, understanding (advocacyeinquiry), and summary (learning points) (Ulrich & Mancini, 2014). The last component of the debriefing was an informal session between each profession’s faculty and their students to discuss discipline-specific responsibilities, accomplishments, challenges, and ideas for improvement.
Lessons Learned Implementing a realistic multi-patient simulation involving a variety of disciplines was a challenge for the faculty. Although many simulation events are conducted in compressed time, we attempted to produce a real-time simulation activity emphasizing the complexity and time constraints commonly encountered in an actual intensive care environment. The number of staff members required to produce the simulation was almost equal to the number learners who participated in the event. Although a clear event timeline was determined before the simulation, individual scenarios were allowed to develop at their own pace in accordance with participants treatment decisions. Each of the four simulation rooms had specific events occurring in them, the sequencing of actual events was strategically mapped out with events in the other rooms. However, it is difficult to know how participants will progress through the multiple scenarios based on length of time to recognition and treatment. In the future, imbedding specific patient events in each patient room while allowing individual scenarios to progress based on student decisions will provide a more realistic flow to the simulation. The timeline needs to detail specific key events so that they do not overlap. However, the timeline also needs to allow additional flexibility based on the participants clinical decision making. We will rely more on the expertise of the ESPs to guide the progression of the scenario and facilitate when the key events occur. One of the most challenging, but unique aspects of the simulation event was having CLS students interact with other simulation participants while they were obtaining specimens and conducting the analysis in a realistic and real-time situation. While the simulation involved four critical patients, CLS students performed multiple laboratory tests on 18 simulated patients to mimic a real laboratory situation. CLS students started 45 minutes earlier than the simulation ensuring these students were included in the actual simulation and debriefing session. Debriefing was difficult to implement because of the students proximity to the simulation center. With 10 minutes remaining in the simulation, the ESP in the student laboratory communicated that the laboratory portion of the simulation was complete and they were to report to the simulation center for debriefing. This allowed time for the
clinical laboratory students to walk to the simulation center. Providing a ‘‘stat’’ laboratory area in the simulation center allows for one laboratory science student to be more actively engaged in conversation and interactions with other professions.
Summary In this article, we described a simulation designed to provide a realistic ICU experience with multiple patients for students from multiple professions. Despite positive efforts in teambased care approaches to health care, communication errors still occur, which can lead to negative patient outcomes. This is why we believe it is increasingly important to educate students on how to effectively work together as a team (Brock et al., 2013). What is novel about this simulation experience is that both its complexity in terms of patients with longitudinal progression over time and the make-up of the interprofessional health care team. During debriefing, it was evident that the simulation positively impacted the learners understanding of professional roles, ways to clearly communicate these roles when working as a team, and the challenges inherent with team communication in the health care setting.
Acknowledgments The University of Alabama at Birmingham Office of Interprofessional Simulation, Chad Epps, MD, Dawn Taylor Peterson, PhD, Marjorie Lee White, MD.
References Baker, C., Pulling, C., McGraw, R., Dagnone, J., Hopkins-Rossell, D., & Medves, J. (2008). Simulation in interprofessional education for patient-centered collaborative care. Journal of Advanced Nursing, 64(4), 372-379. Brindis, R., Rodgers, G., & Handberg, E. (2011). Team-based care: A solution for our health care delivery challenges. Journal of the American College of Cardiology, 57(9), 1123-1125. Brock, D., Abu-Rish, E., Chiu, C. R., Hammer, D., Wilson, S., Vorvick, L., . Zierler, B. (2013). Interprofessional education in team communication: Working together to improve patient safety. British Medical Journal, 22(5), 414-423. Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125. Forsman, R. W. (2002). The value of the laboratory profession in the continuum of care. Clinical Leadership Management Review, 16(6), 370-373. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Katz, C., McNicholas, K., Bounds, R., Figurelle, T., Jones, C., Farley, H., . Johnson, S. (2013). Improving patient safety through enhanced communication between emergency department clinicians and medical laboratory staff. Journal of Communication, 20(10), 455-462.
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Meakim, C., Boese, T., Decker, S., Franklin, A. E., Gloe, D., Lioce, L., . Borum, J. C. (2013). Standards of best practice: Simulation standard I: Terminology. Clinical Simulation in Nursing, 9(6S), S3-S11. Robertson, J., & Bandali, K. (2008). Bridging the gap: Enhancing interprofessional education using simulation. Journal of Interprofessional Care, 22(5), 499-508. Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There’s no such thing as ‘‘nonjudgmental’’ debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55.
Salas, E., Wilson, K., Lazzara, E., King, H., Augenstein, J., Robinson, D., & Birnbach, D. (2008). Simulation-based training for patient safety: 10 principles that matter. Journal of Patient Safety, 4(1), 3-8. Ulrich, B., & Mancini, B. (2014). Mastering simulation: A handbook for success. Indianapolis, IN: Sigma Theta Tau International. Wayne, D., Didwania, A., & Feinglass, J. (2008). Simulation-based education improves the quality of care during cardiac arrest team responses at an academic teaching hospital: A case control study. Chest, 133, 56-61. World Health Organization (2011). WHO patient safety curriculum guide: Multi-professional edition. Retrieved http://whqlibdoc.who.int/ publications/2011/9789241501958_eng.pdf.
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Featured Article
Interprofessional Education: A Multi-patient, Team-Based Intensive Care Unit Simulation Penni Watts, MSN, RN, CHSEa,*, Summer B. Langston, DNP, CRNP, ACNP-BCb, Michelle Brown, MS, MLSc, Charlie Prince, BAd, April Belle, MSN, RNe, Mark Wayne Skipper, BAf, Jerry P. King Jr., RRT, MAEdg, Jacqueline Moss, PhD, RN, FAANh a
Director of Clinical Simulation/Instructor, UAB School of Nursing, Birmingham, AL 35294-1210, USA Assistant Professor, UAB School of Nursing, Birmingham, AL 35294-1210, USA c Assistant Professor, UAB Department of Clinical and Diagnostic Sciences, Birmingham, AL 35294-1210, USA d System Administrator, UAB Office of Interprofessional Simulation for Innovative Clinical Practice, Birmingham, AL 35249-5980, USA e Simulation Coordinator, UAB Hospital, Birmingham, AL 35249-5980, USA f Clinical Simulation Specialist, UAB Office of Interprofessional Simulation, Birmingham, AL 35249-5980 USA g Interim Program Director/Assistant Professor, UAB School of Health Professions, Birmingham, AL 35294-1210 USA h Professor and Chair, UAB School of Nursing, Birmingham, AL 35294-1210, USA b
KEYWORDS interprofessional simulation; clinical laboratory science students; respiratory therapy students; medical residents; nursing students
Abstract: In this article, we describe a multi-patient, team-based simulation experience in an academic setting. We included participants from clinical laboratory science, respiratory therapy, nursing, and medical residents. This simulation allowed students to function as credentialed professionals, focusing on critical thinking, prioritization, effective communication, and teamwork. In order to fully incorporate all professions, we designed an extended-time simulation in which we strategically planned the sequencing of clinical events in each scenario. Because of the complexity of the scenarios, debriefing progressed through three levels: in-room, whole group, and profession specific. Although designing and implementing such a detailed simulation was challenging, we feel it is essential to prioritize teamwork and communication in the academic setting. Cite this article: Watts, P., Langston, S. B., Brown, M., Prince, C., Belle, A., Skipper, M. W., King, J. P., & Moss, J. (2014, October). Interprofessional education: A multi-patient, team-based intensive care unit simulation. Clinical Simulation in Nursing, 10(10), 521-528. http://dx.doi.org/10.1016/j.ecns.2014.05.004. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Delivery of patient-centered care is dependent on a team or network of individuals working together to achieve common patient goals. Such care requires a variety of team
* Corresponding author: [email protected] (P. Watts).
members, including the patient, to have equitable opportunity for input into decision making and communication to produce quality outcomes (World Health Organization, 2011). Patient-centered, team-based care has proven to be an effective, safe approach to care provision. The practice census, a survey of current cardiovascular practices
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.05.004
Interprofessional Education
522
conducted by the American College of Cardiology, found that those operating in team-based settings had increased efficiency (63%), improved quality of care (53%), increased patient satisfaction (50%), and increased staff satisfaction (36%). These teams were also more likely to implement patient education (69%) and internal Key Points communications (63%) as Simulated complex part of standard care protoclinical situations imcols (Brindis, Rodgers, & prove team commHandberg, 2011). unication. Although the move to Creating a realistic ward team-based care is on intensive care unit the rise, accelerating implesimulation offers a mentation of this approach safe environment to will require that students be rehearse team clinical introduced to this concept decision making. early on through educational Strategies are needed programs. The Institute of to support developMedicine makes team-based ment of complex interapproaches to health care a professional simulated priority by encouraging events. funding for demonstrations of interdisciplinary professional education in the Health Resource and Services Administration (Interprofessional Education Collaborative Expert Panel, 2011). Our faculty team sought to develop team training activities through the use of simulation. With a wealth of health professions on our campus, we are able to include multiple professions into a variety of educational experiences. Using simulation for promoting collaboration, teamwork, and improving relationships through team training is an explicit goal of our university. The purpose of this article is to describe a team-based simulation experience involving multiple patient scenarios running simultaneously to prepare students from multiple health care professions to work together to enhance the delivery of effective high quality care and to decrease the potential for error in practice.
Use of Team-Based Simulation One such approach to meeting the need for interprofessional education is through the use of interprofessional simulation. Team-based simulation has been widely used by the military and aviation communities for many years (Salas et al., 2008). Because of its proven success in these areas, this type of training has been applied to patient care and has been shown to improve team skills and employment retention across multiple health care settings (Wayne, Didwania, & Feinglass, 2008). A review of an interprofessional simulation involving nursing students, medical students, and medical residents found that learners perceived simulation-based experiences to be valuable and relevant and that learning in this manner aided in reaching across professional silos
(Baker et al., 2008). In addition, interprofessional simulation in health care education prepares students to more readily enter the clinical setting armed with effective communication and collaboration skills (Robertson & Bandali, 2008; Ulrich & Mancini, 2014).
Institutional Efforts Recognizing the importance of interprofessional education and in keeping in accordance with Institute of Medicine recommendations, the University of Alabama at Birmingham utilizes interprofessional simulation as a tool to introduce students to team-based care in a controlled environment (Ulrich & Mancini, 2014). At the University of Alabama at Birmingham, the Office of Interprofessional Simulation for Innovative Clinical Practice, a universitywide center that brings together staff, faculty, and students, has been established to ensure that goals for interprofessional education are met. The center is comprised of faculty and staff from multiple disciplines who work collaboratively to plan and implement interprofessional simulation activities. Some such activities are weekly simulations that involve students from multiple health professions schools. These simulations take place in our partner health care facility and are part of an ongoing endeavor to continue the integration of simulation into respective health profession curricula. These simulation experiences are often brief, which makes it challenging to focus on all the core competencies outlined by Interprofessional Education Collaborative (IPEC) (Interprofessional Education Collaborative Expert Panel, 2011). Table 1 summarizes the IPEC competencies. Because of the time constraints of the brief weekly multiprofessional simulations, a group of interdisciplinary faculty sought to use the IPEC competencies as a framework for the development of a multi-patient, multiprofessional, extended simulated session. This extended simulation session would aid in reinforcing the core competencies for the clinical laboratory science (CLS), medicine, nursing, and respiratory therapy students that participated in the weekly interprofessional simulations. These competencies were built into the heart of the extended simulation, which was designed to challenge learners by creating an experience with significant complexity to allow for critical thinking, prioritization, and team-based communication in a critical care setting. As part of our institutional efforts in team training, we have developed learning activities for a variety of students from multiple professions. In this learning activity with real-time simulation, we were able to include laboratory science students to simulate specimen analysis in a compressed time frame. Involving laboratory students is a novel way to improve collaboration and communication in clinical practice. There are few publications documenting the involvement of the clinical laboratory in interprofessional
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Interprofessional Education Collaborative Core Competencies
Core Competency
Basic Principles
Value/ethics for interprofessional practice Roles/responsibilities Interprofessional communication Teams/teamwork
Mutually respectful relationships; professions add insight; and diversity Acknowledges team complexity and role clarification Essential for safe care and streamlined approach Patient-centered goals and shared expertise
Source: Interprofessional Education Collaborative Expert Panel, 2011.
simulation experiences. In a report from the Mayo Clinic Department of Laboratory Medicine it was noted that the clinical laboratory provides data that influence 60% to 70% of clinical decisions (Forsman, 2002). Enhancing communication between the laboratory and clinical staff directly improves patient safety (Katz et al., 2013).
volunteer participants. This interprofessional multi-patient simulation was designed to mimic an afternoon in the intensive care unit (ICU) to provide a realistic exercise in critical thinking, dynamic prioritization, effective communication, and teamwork.
Scenarios
Overview of the Simulation This simulation experience was designed to use an interactive scenario to encourage students to prioritize patient care and communicate effectively with other members of the health care team to offer safe, quality health care. Four scenarios, run simultaneously over 90 minutes, provided challenges for two second-year medical residents, eight nursing students, three respiratory therapy students, and three CLS students. Student participation at the event was required by some program faculty as part of a specific course while other students were
Table 2
Four simulated ICU patient cases were developed that included a range of common medical ICU conditions. Two of the simulated patients were recent admissions; and one patient had resided in the ICU for 2 weeks. The fourth patient was admitted from the emergency department during the simulation. An overview of the scenarios can be found in Table 2. Each patient had a planned progression of events, which would occur during the extended simulation. Timing the events in the simulation played an integral part in providing an opportunity for the participants to prioritize care according to the available resources. The outcomes of the patients were a direct result of the care
Scenario Summary
Case
Diagnoses
Presentation
Outcome
Lewis Upper gastrointestinal bleed Abernathy with liver failure and blood transfusion reaction transfusion-related acute lung injury (TRALI) Gayle Sepsis, suspected pulmonary Redmond embolism, and pulseless electrical activity (PEA) arrest
Severe hypotension Needs consent for blood, central venous line, arterial line, esophagogastroduodenoscopy
Respiratory distress Blood transfusion reaction Requires endotracheal intubation
Admitted from nursing home Slight respiratory distress Requires high-flow nasal cannula and computed tomography angiography of the chest
Norman Bradshaw
Chronic obstructive pulmonary disease exacerbation
Newly admitted from the emergency room Respiratory distress
Diego Sanchez
Pneumonia, ventilator weaning, and medical equipment troubleshooting
Critical laboratory values: blood glucose ¼ 25 and serum potassium ¼ 2.3 PEA arrest Requires cardiopulmonary resuscitation, endotracheal intubation, and central venous line placement Requires positive pressure ventilation Refuses endotracheal intubation Accepts noninvasive positive pressure ventilation Code statusddo not resuscitate Cuff leak develops Endotracheal tube changed Vent weaning continued as ordered
Admitted 12 days ago with pneumonia Intubated 10 days ago Failed vent wean 5 days ago Ready to wean and weaning in progress
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Simulation Timeline
Case
Facilitators
1345
Lewis Computer operator, Abernathy voice, ESP, and family member
Gayle Redmond
Computer operator, voice, ESP, and family member
Norman Bradshaw
Computer operator, voice, ESP, and family member
Diego Sanchez
Computer operator, voice, ESP, and family member
Stat laboratory
ESP
Main laboratory
ESP
1430
1500
1510
Prebrief orientation RN shift report: needs second IV HR, 110; BP, 92/47; RR, 25; and O2 sat 95% on 5 L Prebrief orientation RN shift report: needs 20 g IV for CT HR, 95; BP, 95/37; RR, 28; O2 sat 90%; temperature, 101.3 F Prebrief orientation RN shift report: Pt not arrive to unit yet Prebrief orientation RN shift report: Wean from vent HR, 75; BP, 129/72; RR, 18; and O2 sat 99% Rapid hCG received through tube system
MD and RT checkout HR, 132 and BP, 68/37
Responds to fluids Needs consent for blood and CVL Blood ready
MD and RT checkout O2 sat 89%
O2 sat 88%
Prebrief orientation Receive specimens to send to main laboratory Prebrief orientation Analyze prioritized Specimen specimens prioritization Proceed with testing
MD and RT checkout
MD and RT checkout
Rapid Strep test received through tube system
Receive specimens on Redmonddrejected, hemolysis
Analyze prioritized specimens
Notify nurse that blood is ready
Note. ESP ¼ embedded simulation participant.
given during the simulation. There were no planned patient deaths.
Collaboration Platform During the conception and development phase of this ICU simulation, it was necessary to share documents between multiple facilitators across our large institution. To prevent an overwhelming amount of e-mail exchanges, and to prevent multiple concurrent versions of the documents related to this event, we decided it was best to utilize Microsoft SharePoint 2010 to address these issues. SharePoint 2010 is a platform for collaboration, content management, business intelligence, data warehousing, and creating intranets and public-facing websites. The Office of Interprofessional Simulation already had an extensive intranet, so it was easy to partition off some new space to dedicate to this ICU simulation. In this new space, a document library was created that allowed the facilitators of this event to edit the same documents collaboratively, while retaining versions of everyone’s edits. This document library also provided a layer of security, as permissions to
access it were strictly limited to the participating facilitators, thereby requiring authentication with their credentials. Ultimately, SharePoint served its purpose in preventing dozens of versions of the same document from floating around multiple e-mails, as well as serving as a central location to securely store these documents.
Simulation Designing a multi-patient ICU simulation with four professions required extensive planning and scripting. The simulation event manager developed case stems and worked in conjunction with the other professions to fill in appropriate case details ensuring accuracy from each perspective. Because of the complexity of each case and the many moving parts, a timeline was created for organization and sequencing of events during the simulation as shown in Table 3. This timeline was created to provide clear directions for the embedded simulation participants (ESPs), simulation operators, faculty, and staff facilitating the experience. Throughout the 90-minute simulation experience, events such as changes in the patients’ clinical
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(Continued)
1518
1520
Bring pickup slip for red Transfuse packed red cells to stat laboratory blood cells (RBCs) to get blood
Slight distress, O2 sat 87%, high-flow NC up to 94%
1530
1535
Post-transfusion vitals: HR, 130 and BP, 75/42
1545 Acute respiratory distress from transfusion TRALI Intubate pt HR, 132; BP, 73/40; RR, 38; and O2 sat 88%
Back from CT; has PEA arrest; and requires CPR, ETT, and CVL
Receive call from laboratory with critical resultsdglucose and potassium Patient admitted in distress and refuses intubation
Family arrives and code status discussion
O2 sats dropdETT cuff leak HR, 127; BP, 167/72; O2 sat 87%; and RR, 30
Change ETT
Issue packed RBCs to nurse
Rapid flu test
Receive specimens on Abernathydrejected, not labeled correctly
Laboratory call to reject clotted CBC on Abernathy
Analyze prioritized specimens
Call critical result to RNdglucose, 25 mg/ dL and potassium, 2.3 mEq/L
Analyze prioritized specimens
Analyze prioritized specimens
conditions, critical laboratory analysis and results, patient transport, and an emergency patient admission all required students to apply clinical decision-making and teamwork skills. ESPs facilitated the simulation portraying family members, clinicians, a laboratory supervisor, and one as a simulated patient. The simulation took place in the simulation center staged to resemble a four-bed ICU. The experience included a total of four simulated patients; three highfidelity human patient simulators were used to allow students to practice interventions such as intubation, urinary catheter insertion, and chest compressions, whereas one faculty actor was used for realistic interaction and communication regarding end-of-life counseling. Two nursing students were assigned to each patient. They were given a full verbal and written handoff report from an ESP as the off-going nurse, before beginning their shift assessments. The nursing students began the simulation 15 minutes before the medical residents and respiratory therapy students. During this time, the medical residents and respiratory therapy students received a full handoff report. The CLS students were split into two groups, and
one student was assigned to the simulation center along with one faculty member who worked in the simulated onsite clinical laboratory. The other students were located off site across campus with another ESP and communicated with the health care team by phone as they ran laboratory tests in the on-campus simulated clinical laboratory.
Simulation Setup Intensive Care Unit In the simulation laboratory, a total of four simulated patient rooms were utilized. One room was permanently staged to host operating room simulations, the remaining rooms were set up much like conventional intensive care patient rooms with supply cabinets, a stretcher, and a head wall with electrical outlets, air, and oxygen. These rooms housed the three high-fidelity simulators (CAE Healthcare HPS, a Laerdal SimMan 3G, and a Laerdal SimMan Essential) and the one standardized patient. The standardized patient was wheeled into the unit on a stretcher roughly 30 minutes after the simulation had begun, thus
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simulating a new patient admission through the emergency department. An adjacent administrative area was converted to provide counter space for the laboratory to sort samples and make telephone calls. Within the simulation center, two control rooms were used to operate three simulators. While one person controlled a simulator from the operating room’s control room, two more operators and an actor portraying the voice of a patient worked from the main control room. The operators were assisted by the facilitators or circulators who interacted with the learners and reported back to the operators as needed, allowing for those operating the simulators to adjust to the learners’ actions as the cases progressed. Moulage of the manikins was kept to a minimum for this ICU simulation. Each manikin was outfitted with IV lines, a urinary catheter, or other devices as needed to match the patient scenario. Supplies such as IV tubing and fluids, medications, urinary catheters, and general medical supplies were stocked in carts outside each simulation room. Crash carts were stocked and prepared with intubation equipment, a defibrillator, and similar supplies found on standard crash carts in the hospital. Each scenario was accompanied by a full shift report and a medical record complete with an appropriate medical history and physical, a list of home medications, laboratory results, vital signs, intake and output, progress notes, medication administration record, procedure notes, and imaging reports. Participants were encouraged to perform as licensed professionals even if they were students. The students were expected to assess their patients and work together to determine appropriate interventions such as fluid resuscitation, blood administration, medication administration, appropriate oxygen and/or ventilation therapy, laboratory analysis, troubleshooting medical equipment, and cardiopulmonary resuscitation. Clinical Laboratory Two laboratories were prepared and staffed by CLS students and ESPs. One was a ‘‘stat’’ laboratory in the ICU where rapid testing was performed. This also served as a specimen receiving area for laboratories drawn during the simulation. The second laboratory, offering a full array of laboratory diagnostics, was located in the student’s learning laboratory in the CLS building on the University’s campus. Real blood specimens were analyzed and therefore required a biosafety Level 2 laboratory. This also accurately reflects the reality that the laboratory is often not near the ICU, since it serves the entire hospital as well as providing an opportunity for students in the ICU to communicate with students at the laboratory via telephone. Also, having one group of clinical laboratory students off site was part of the simulation design plan to mimic a realistic portrayal of health care facilities in which the laboratory is not always near in proximity, and there may in fact be some delay in the processing of specimens.
In preparation for the scenario, it was necessary to ensure there were samples for the laboratory students to analyze that were not related to the four patients in the simulation. In the real clinical setting, when the laboratory receives a call about a particular patient, the scientist has to sort through potentially hundreds of other patient samples and results to find what the clinician needs. Multiple real human blood specimens for 18 patients were prepared. These specimens were evaluated in multiple disciplines within the laboratory: blood bank, hematology, chemistry, and microbiology. Each laboratory order included a test requisition, specimen, and relevant patient history. There were functioning telephones in the laboratory as well as the ICU simulation area to facilitate communication of results, blood product availability, and specimen acceptability.
Prebriefing The purpose of prebriefing is to communicate to the student that this is a safe learning environment before the simulation experience. Students are given information or preparatory instructions that help the participants achieve the scenario objectives (Meakim et al., 2013). Prebriefing of students occurred before the simulation and involved multiple components including confidentiality, the fiction contract, our basic assumptions, as well as instructions for learners to access data, equipment, and supplies (Meakim et al., 2013). Prebriefing and discussion of the case stem was organized by discipline. CLS students were the first group of students to be briefed 45 minutes before the commencement of the simulation allowing them to begin specimen analysis and to report results at appropriate times throughout the simulation.
Debriefing Debriefing for such a large and complex simulation presented many challenges. All students underwent extensive debriefing on three levels: scenario, simulation, and profession. To accomplish this, debriefing was performed according to the following: in-room (scenario), large conference room (all simulation participants), and disciplinespecific breakout sessions (profession). Immediately after the simulation, students and ESPs remained in their respective rooms for the initial in-room debriefing. Facilitators reviewed case-specific reflection and discussion utilizing the plus and/or delta debriefing technique (Fanning & Gaba, 2007). Following the in-room debriefing, participants gathered in a large conference room for the large group interprofessional debriefing. To address multiple disciplines in the simulation, the majority of the debriefing time was dedicated to discussion of time management, interprofessional communication, and teamwork. This debriefing was facilitated by two lead debriefers with cofacilitators by each student group’s faculty member.
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Structure of this portion of the debriefing was modeled after debriefing with good judgment (Rudolph, Simon, Dufresne, & Raemer, 2006; Ulrich & Mancini, 2014). This debriefing included three phases: reactions, understanding (advocacyeinquiry), and summary (learning points) (Ulrich & Mancini, 2014). The last component of the debriefing was an informal session between each profession’s faculty and their students to discuss discipline-specific responsibilities, accomplishments, challenges, and ideas for improvement.
Lessons Learned Implementing a realistic multi-patient simulation involving a variety of disciplines was a challenge for the faculty. Although many simulation events are conducted in compressed time, we attempted to produce a real-time simulation activity emphasizing the complexity and time constraints commonly encountered in an actual intensive care environment. The number of staff members required to produce the simulation was almost equal to the number learners who participated in the event. Although a clear event timeline was determined before the simulation, individual scenarios were allowed to develop at their own pace in accordance with participants treatment decisions. Each of the four simulation rooms had specific events occurring in them, the sequencing of actual events was strategically mapped out with events in the other rooms. However, it is difficult to know how participants will progress through the multiple scenarios based on length of time to recognition and treatment. In the future, imbedding specific patient events in each patient room while allowing individual scenarios to progress based on student decisions will provide a more realistic flow to the simulation. The timeline needs to detail specific key events so that they do not overlap. However, the timeline also needs to allow additional flexibility based on the participants clinical decision making. We will rely more on the expertise of the ESPs to guide the progression of the scenario and facilitate when the key events occur. One of the most challenging, but unique aspects of the simulation event was having CLS students interact with other simulation participants while they were obtaining specimens and conducting the analysis in a realistic and real-time situation. While the simulation involved four critical patients, CLS students performed multiple laboratory tests on 18 simulated patients to mimic a real laboratory situation. CLS students started 45 minutes earlier than the simulation ensuring these students were included in the actual simulation and debriefing session. Debriefing was difficult to implement because of the students proximity to the simulation center. With 10 minutes remaining in the simulation, the ESP in the student laboratory communicated that the laboratory portion of the simulation was complete and they were to report to the simulation center for debriefing. This allowed time for the
clinical laboratory students to walk to the simulation center. Providing a ‘‘stat’’ laboratory area in the simulation center allows for one laboratory science student to be more actively engaged in conversation and interactions with other professions.
Summary In this article, we described a simulation designed to provide a realistic ICU experience with multiple patients for students from multiple professions. Despite positive efforts in teambased care approaches to health care, communication errors still occur, which can lead to negative patient outcomes. This is why we believe it is increasingly important to educate students on how to effectively work together as a team (Brock et al., 2013). What is novel about this simulation experience is that both its complexity in terms of patients with longitudinal progression over time and the make-up of the interprofessional health care team. During debriefing, it was evident that the simulation positively impacted the learners understanding of professional roles, ways to clearly communicate these roles when working as a team, and the challenges inherent with team communication in the health care setting.
Acknowledgments The University of Alabama at Birmingham Office of Interprofessional Simulation, Chad Epps, MD, Dawn Taylor Peterson, PhD, Marjorie Lee White, MD.
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