If I only knew then what I know now…
Presented by:Cynthia G. Cunningham, MSN, RN
Southwestern Virginia’s Regional Clinical Simulation Centers
State Council of Higher Education in Virginia (SCHEV) and regional nursing programs met to explore ways of partnering with public and private entities to:Maximize the use of scarce resourcesAddress the shortage of nursing facultyExplore alternatives for nursing student clinical education
June 8, 2005
Radford University
Jefferson College of Health Sciences
Wytheville Community College
New River Community College
Virginia Western Community College
Patrick Henry Community College
THE PARTNERSHIP Collaboration of nursing educators to develop strategies to address the shortage
Developed the CSC conceptSubmitting CSC proposal to SCHEVProposal was included in the Governor’s Budget for the next bienniumFunding for the project was allocated to Radford University in July 2006
RU SON ASSUMED LEADERSHIP
To alleviate the shortage of nurses in Virginia by increasing the capacity of nursing schools to enroll students, maximizing use of faculty resources, and decreasing competition for scarce clinical sites
OVERALL GOAL OF THE CSC
The Clinical Simulation Center’s will provide a hands-on learning experience in an environment that is safe and realistic, producing quality nurses with enhanced critical thinking abilities, communication skills and collaboration experience
VISION
THE BUSINESS PLAN
History Profile
Business Summary Product/Services Industry Analysis Marketing Analysis Organization/
Management
Financial Section Assumptions Revenue Streams CSC Budgetary
Projections Personnel Operating
Equipment Lists
The renovation
SIMmares
Definition: Simulation based “disturbing” dreams. Typically
occurring between 3am - 5am. Occasionally may happen during the day.
Renovation/Space Planning Team
CSC Director
Facilities Planning
and Constructi
on
Create-a-lab Rep
Laerdal Sales Rep
Education Management
Solutions (EMS) Hardware Design
Specialist
My renovation team is gone and I don’t know
what I am doing….
SIMmare #1
•Laerdal rep decided to change territories• Wanted to move back to Texas …………
•Education Management Solutions (EMS) rep decided traveling was not conducive to a personnel life!
• Was married within a year
•Create-a-lab rep decided to start a family• Had a bouncing baby boy
Renovation team turn over…...
Do you think it could be me?!!!!
I would have an exit review with any renovation team member leaving the project. I would visit more SimCenters and ask more questions r/t design I would participate in more SUN’s
If I knew then what I know now
And if necessary ………….
Great for entertaining …..boating…..fishing……relaxing...
I live on the Lake and have a boat and SeaDoo…
……..and they are great with children
I have two Newfoundlands
I ASSuME’d and my new team members
ASSuME’d
Due renovation team turn-over
The control room
SIMmare #2
CONNECTIVITY
I would have clear operational expectations – central control room separate from SIMroom with A/V observation I would include IT in the renovation team I would include – SimPhones to connect each SimRoom to each control room operating station
If I knew then what I know now
My SIMteam
RU SON
CSC Director (MSN)
RHEC Site
RU West Site
VWCC PHCC JCHS RU WCC NRCC RU
2 MSN’s, 1 IT Specialist1 Admin
Specialist II
2 MSN’s, 1 IT Specialist1 Admin
Specialist II
Receiving and Installing 1.9 Million Dollars of Equipment
SIMmare #4
Of course spending was not the nightmare….Receiving, installing and tagging all items > $5000 and all IT equipment was!
Include “on-site delivery & installation” in purchasing agreement
Receiving Equipment - Laerdal Hum
m
This doesn't
look good
– manikins, room furnishings, task trainers, virtual IV……
Laerdal representative after receiving equipment
Purchasing Agreement
Sturgis DREAMS: Russell
returns to Virginia
Installing Equipment
Room set-ups per site:
1 Med/Surg SimRoom 1 ICU SimRoom 1OB SimRoom 1 Pediatric SimRoom 2 Exam Rooms 1 Multipurpose
classroom with 3-5 patient beds
Simulation Apartment Computer Classroom
Manikin Assembly: 4 SimMan 4 SimBaby 2 Nursing & 2 ALS Anne’s 2 MegaCode & 2 Nursing
Kelly’s 2 Nursing & 2 MegaCode Kid’s 2 Nursing Baby 2 Noelle 4 Adult & 2 Peds Virtual IV, …….
Installing Equipment - Laerdal
Ouch!SimMan kicked me!
SimMan, try to
behave yourself
Laerdal representative after installation of equipment
Sturgis DREAMING
:My new
territory …TEXAS!
Installing A/V & IT equipment
Room set-up x 7 per site:
2 Pan Tilt Zoom Cameras Microphone Cabling between room and
control room to connect (cat 5, extender boxes)
Cabling between room and server room (A/V connections)
Cabling between control room and server room
Server Room: 2 DVR’s 2 computers to control
DVR 1 computer to manage
video 1 SQL server (database) 1 IIS server (web) 1 Quantum Tape Library 1 SNAP Server for video
storage
Installing A/V & IT equipment
I would hire 1 IT specialist and 5 MSNs: Rationale for one IT specialist:
A bored IT leads to a gone IT Most everything can be fixed remotely Standardization between sites
Rationale for Additional MSN: Increased capacity of student’s served (450
students/semester) Increased volume of scenarios produced Back-up for staffing due to illness/surgery, time off….
If I knew then what I know now
Manikin responses are not in sync with monitor readings
or scenario program
SIMmare #5
Another CONNECTIVITY Problem
Nine Pin Problem
PROBLEM: Cable extender
box – nine pin connection – transmission delays between control room and manikin. Manikin pulses and heart rate did not correlate with programmed settings and monitor waveforms (EKG, Pulse…)
SOLUTION: Pull nine-pin cable
through wall/ceiling and directly connect to laptop, i.e., by passing the rose boxes.
I would request that integrating equipment be tested with the manikin system prior to purchase or include a contingency plan for beta testing in the purchasing agreement
If I knew then what I know now
CONTROL ROOM
Imagine: No Monitors
Imagine:No plan to connect manikin to the Laptop
MED/SURG ROOM
OB ROOM
PEDIATRIC ROOM
INTENSIVE CARE ROOM
DEBRIEFING ROOM
Lessons Learned Over TIME
Student driven Organization
Admission ticket Incorporate pre/post
encounter evaluation and add NCLEX ? to pre
Reinforce concepts/nursing process included in “admission ticket”, pre-encounter, and scenario
Incorporate NCLEX ?s
Start early…
Partner and/or barter with as many organizations as possible
Charge fee for unused time Block scheduling
Scenario Development Revenue Planning
Student Preparation & Evaluation
Organized Debriefing
Partnering/Bartering
Scheduling
Curriculum Integration
Orientation Boot-camps
Fundamental Front-loading
Standardized patient encounters Mental health Assessment, H&P
Follow course syllabus when choosing scenario
Consider fidelity
Choose the “right” manikin/SP for the simulation
If equipment is needed actually use the equipment – headwall O2/suctioning, IV pump, 12-lead….
Include supporting documentation – SIMChart
Suspend disbelief – do not ask students to “pretend” or use phrases like “if you were taking care of a real patient….you would…..
Student Driven NOT Operator Driven
Student intervention or non-intervention dictates manikin action
All vocals are pre-recorded Use handlers for all actions that
are not tied to time or sequencing If sequencing is important,
incorporate standardized cues (vocal, manikin action)
Lessons Learned
SCENARIO DEVELOPMENT & REVIEW & STORAGE
Scenario Development Process
Standardized event menus Indicate events with v. if vocal is
attached Lab reports, xrays,…as pdf files to
display on pt. monitor Scenarios reviewed & revised every
summer to insure best practice
Lessons Learned
Shared scenario storage system
“FinalSim” houses all up-dated scenarios - batch file runs every night to load to Laerdal computers
SCENARIO DEVELOPMENT & REVIEW & STORAGE
Scenario Storage
Lessons Learned
Need better criteria to assess preparedness.
Too much information in post encounter evaluation
Information is fragmented – inconsistent flow from prep work through post encounter evaluation.
All scenarios have an admission ticket – student must complete the admission ticket to participate in the simulation
Incorporate a pre-encounter and post-encounter student questionnaires
Incorporate nursing process in pre/post encounter evaluation
Incorporate NCLEX question in pre-encounter and into debriefing
Assessing Preparedness Solutions to Assessing Preparedness
Data Collection
The bigger picture
Solutions to Data Collection
Solution to making a bigger impact
Preparation-Evaluation-Debriefing Putting it all
Together
Name: Date: Instructor:
Simulation Learning Objectives: 1. Utilize patient laboratory results and assessment findings to guide medication administration. 2. Insert foley catheter utilizing aseptic technique. 3. Utilize nursing measures and physician orders to maximize gas exchange and decrease cardiac workload. 4. Conduct focused assessment pertinent for patient with CHF.
Scenario: CHF Patient: Willie Morrison Gender: Female Age: 86 Weight: 44.5 kg Height: 152.4 com Expected Simulation Run Time: 30 minutes Location: PCU
Patient Information: Increasing shortness of breath and muscular weakness over the past week with non-productive cough and chest pain. Past Medical History: Atrial fibrillation, congestive heart failure, non-insulin dependent diabetes mellitus, osteoporosis, vitamin D deficiency, hyperlipidemia, hypertension Allergies: angiotensin converting enzyme inhibitors Social History Widow; retired elementary school teacher; no history of alcohol or tobacco use; one daughter lives next door and is her primary caretaker Surgeries/Procedures: Open reduction and internal fixation of right hip fracture 5 years ago; bilateral cataract extractions with intraocular lens placement; vertebroplasty Please review the following PRIOR to your simulation experience:
Intravenous potassium and lasix, PO lanoxin, coumadin, fosamax, calcium, vytorin, glyburide, lopressor, imdur, ASA, regular insulin Possible skills: foley catheter insertion, use of infusion pump Pathophysiology of atrial fibrillation, congestive heart failure, type 2 diabetes, osteoporosis Focused assessments pertinent to diagnoses
Ancheta, I. (2006). A Retrospective Pilot Study: Management of Patients with Heart Failure. Dimensions of Critical Care Nursing, 25(5), 220-233. Deglin, J., & Vallerand, A. (Eds.). (2007, April 19). Potassium Supplements [Electronic version]. In Davis's Drug Guide for Nurses. Retrieved from STAT!Ref Online Electronic Medical Library: http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=846&FxId=58&S Hilton, P. (Ed.). (2004). Fundamental Nursing Skills. Philadelphia: Whurr Kozier, B., Erb, G., Berman, A., & Snyder, S. (2002). Techniques in Clinical Nursing: Basic to Intermediate Skills (5th). Upper Saddle River, New Jersey: Prentice Hall. Skidmore-Roth, L. (2004). 2004 Mosby's Nursing Drug Reference. St. Louis: Mosby. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (11th ed.). Philadelphia: Lippincott, Williams, & Wilkins .Sole, M., Klein, D., & Moseley, M. (2005). Introduction to Critical Care Nursing (4th Ed.). St. Louis: Elsevier.] Hypokalemia-New Treatments. (May 2, 2007). Retrieved September 16, 2007, from Library of the National Medical Society: http://www.medical-library.org/journals2a/hypokalemia.htm
Questions to Answer Prior to Simulation Session (Please staple answers to the questions below to this ticket for admission to simulation session. Without this ticket and completed questions you will not be allowed to participate in the scheduled scenarios). The completed questions will be turned in and checked by your class instructor. 1. List the 2 most important care priorities for a patient with congestive heart failure? 2. What are the clinical manifestations of hypokalemia? 3. What is the target/goal PT/INR for a patient on Coumadin for atrial fibrillation? 4. Describe the differences in presentation/symptomatology between a patient with left–sided vs. right-sided heart failure.
Lessons Learned
Student driven Incorporate admission
ticket questions, pre-encounter into discussion
Video review NCLEX question review
Debriefing
1. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of warfarin (Coumadin) 2.5 mg. The serum international normalized ratio (INR) is 4.7. What intervention should the nurse be prepared to initiate?
1. Observe the client for a possibility of an embolic event.
2. Have a partial prothrombin time (PTT) drawn to completely evaluate the level of anticoagulation.
3. Prepare to administer protamine sulfate.
4. Monitor the client for signs of bleeding.
1. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of warfarin (Coumadin) 2.5 mg. The serum international normalized ratio (INR) is 4.7. What intervention should the nurse be prepared to initiate?
1. Incorrect. If the client were at risk for an embolism, the INR would be very low, reflecting inadequate anticoagulation.
2. Incorrect. PTT evaluates anticoagulation levels as a result of heparin, not warfarin.
3. Incorrect. Protamine sulfate is the antidote for heparin, not warfarin.
4. Correct. The level of anticoagulation, as reflected by the INR, is too high and the client is at risk for bleeding. The serum INR is done to reflect the effectiveness of oral anticoagulants, especially warfarin. The normal value is 2.0-3.0 for clients on anticoagulation therapy.
Test-Taking Tip: Because the drug is a anticoagulant, choose the “assessment” type of answer for the one most related to anticoagulant therapy. Eliminate answers 2 and 3 since r/t heparin.
Lessons Learned
Nursing Process Driven Medication error reporting Curriculum integration
questions
RAGE
Evaluation
Any questions?