Foundation Programme > Scenario 7 Version 9 – May 2015 1 Editor: Dr Andrew Darby Smith Original Authors: Author: L Williamson, J Bowen, N Feely ACUTE ASTHMA (ED) MODULE: ACUTE CARE TARGET: FY1 & FY2 TRAINEES AND FINAL YEAR MEDICAL STUDENTS BACKGROUND: In the UK there are more than 1000 deaths each year from asthma (approximately 3 every day). It is estimated that up to 90% of these deaths are preventable. Healthcare professionals must be able to recognise the signs of life-threatening and near-fatal asthma, be able to implement immediate treatments and know when to refer to critical care. FY2 trainees should be able to work within and lead a team to safely assess and treat asthmatic patients in a timely manner. RELEVANT AREAS OF THE FOUNDATION PROGRAMME CURRICULUM 1 Professionalism 1.4 Team Working: • Demonstrates clear and effective communication within the team 1.5 Leadership: • FY2 demonstrates extended leadership role by making decisions and dealing with complex situations across a greater range of clinical and non-clinical situations 7 Good clinical care 7.5 Safe prescribing • Prescribes drugs and treatments appropriately, clearly and unambiguouslyin accordance with Good Practice in Prescribing Medicines (GMC, 2008) • Uses the BNF plus pharmacy and computer-based prescribing-decision support to access information about drug treatments, including drug interactions • Performs dosage calculations correctly and verifies that the dose is of the right order • Chooses appropriate intravenous fluids as vehicles for intravenous drugsand calculates the correct volume and flow rate • Prescribes oxygen appropriately including to patients with the risk of carbondioxide retention • Relates prescribing activity to available prescribing guidelines / audit data egantibiotic usage 7.7 Infection control and hygiene • Demonstrates correct techniques for hand hygiene with hand gel and with soapand water • Takes appropriate microbiological specimens in an timely fashion • Follows local guidelines / protocols for antibiotic prescribing 7.9 Interface with different specialties and with other professionals • Understands the importance of effective communication with colleagues inother disciplines
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FoundationProgramme>Scenario7
Version9–May2015 1 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
ACUTEASTHMA(ED)MODULE:ACUTECARE
TARGET:FY1&FY2TRAINEESANDFINALYEARMEDICALSTUDENTS
BACKGROUND:
In the UK there are more than 1000 deaths each year from asthma (approximately 3 every day). It isestimated that up to 90% of these deaths are preventable. Healthcare professionals must be able torecognise the signs of life-threatening and near-fatal asthma, be able to implement immediatetreatments and knowwhen torefer tocriticalcare. FY2 trainees shouldbeabletoworkwithinand leadateamtosafelyassessandtreatasthmaticpatientsinatimelymanner.
RELEVANTAREASOFTHEFOUNDATIONPROGRAMMECURRICULUM
1Professionalism
1.4TeamWorking:• Demonstratesclearandeffectivecommunicationwithintheteam
1.5Leadership:• FY2demonstratesextendedleadershiprolebymakingdecisionsanddealingwith
complexsituationsacrossagreaterrangeofclinicalandnon-clinicalsituations
7Goodclinical
care
7.5Safeprescribing• Prescribesdrugsandtreatmentsappropriately,clearlyandunambiguouslyin
accordancewithGoodPracticeinPrescribingMedicines(GMC,2008)• UsestheBNFpluspharmacyandcomputer-basedprescribing-decisionsupportto
accessinformationaboutdrugtreatments,includingdruginteractions• Performsdosagecalculationscorrectlyandverifiesthatthedoseisoftherightorder• Choosesappropriateintravenousfluidsasvehiclesforintravenousdrugsand
calculatesthecorrectvolumeandflowrate• Prescribesoxygenappropriatelyincludingtopatientswiththeriskofcarbondioxide
retention• Relatesprescribingactivitytoavailableprescribingguidelines/auditdataegantibiotic
usage7.7Infectioncontrolandhygiene• Demonstratescorrecttechniquesforhandhygienewithhandgelandwithsoapand
water• Takesappropriatemicrobiologicalspecimensinantimelyfashion• Followslocalguidelines/protocolsforantibioticprescribing
7.9Interfacewithdifferentspecialtiesandwithotherprofessionals• Understandstheimportanceofeffectivecommunicationwithcolleaguesinother
disciplines
FoundationProgramme>Scenario7
Version9–May2015 2 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
8Recognitionand
managementoftheacutelyill
patient
8.1Promptlyassessestheacutelyill,collapsedorunconsciouspatient• UsesAirway,Breathing,Circulation,Disability,Exposure(ABCDE)approachto
assessingtheacutelyunwellorcollapsedpatients• UsestheGCSorAlert,Voice,Pain,Unresponsive(AVPU)toquantifyconsciouslevel• Investigatesandanalysesabnormalphysiologicalresultsinthecontextoftheclinical
scenariotoelicitandtreatcause• Usesmonitoring(includingbloodglucose)toinformtheclinicalassessment• Askspatientsandstaffappropriatequestionstoprioritisecare• Seeksseniorhelpwiththefurthermanagementofacutelyunwellpatientsboth
promptlyandappropriately• Summarisesandcommunicatesfindingstocolleaguessuccinctly• Appropriatelycommunicateswithrelatives/friendsandofferssupport
8.2Respondstoacutelyabnormalphysiology• Formulatestreatmentplaninresponsetoacutelyabnormalphysiologytakinginto
accountotherco-morbiditiesandlong-termconditions• Administersandprescribesoxygen,fluidsandantimicrobialsasappropriate(seeGood
ClinicalCare:SafePrescribingandInfectionControl)• Recogniseswhenarterialbloodgassamplingisindicated,identifiesabnormalresults,
interpretsresultscorrectlyandseekssenioradvice• Plansappropriateactiontotrytopreventdeteriorationinvitalsigns• Reassessesillpatientsappropriatelyafterstartingtreatment• Recognisestheindicatorsforintensivecareunitreviewwhenphysiologyabnormal
8.3Managespatientswithimpairedconsciousness,includingseizures• Assessesconsciouslevel(GCSorAVPU)• Treatsongoingseizures• Recognisescausesofimpairedconsciousnessandseizuresandseekstocorrectthem• Recognisesthepotentialforairwayandrespiratorycompromiseintheunconscious
patient(includingindicationsforintubation)• Understandstheimportanceofsupportivemanagementinimpairedconsciousness• Seeksseniorhelpforpatientswithimpairedconsciousnessinanappropriateand
timelyway
11Investigations
11.1Investigations• Requestsinvestigationsappropriateforpatients’needsinaccordancewithlocaland
nationalguidancetooptimisetheuseofresources• Seeksout,recordsandrelaysresultsinatimelymanner• Plans/organisesappropriatefurtherinvestigationstoaiddiagnosisand/orinformthe
managementplan• Providesconcise,accurateandrelevantinformationandunderstandsthediagnostic
questionwhenrequestinginvestigations• Understandswhatcommontests(Table1)andproceduresentail,thediagnostic
limitationsandcontraindications,inordertoensurecorrectandrelevantreferrals/requests
• Interpretstheresultscorrectlywithinthecontextoftheparticularpatient/presentatione.g.plainradiographyinacommonacutecondition
• Prioritisesimportanceofinvestigationresults
FoundationProgramme>Scenario7
Version9–May2015 3 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
INFORMATIONFORFACULTYLEARNINGOBJECTIVES:
• ABCDEassessmentandinitialmanagementofpatientwithlife-threateningasthma
• Earlyrecognitionofprogressiontolife-threatening/near-fatalasthma
• Appropriatecallforhelpandconcisetransferofinformation(+/-assistingcriticalcareteamifcontinuetophase(b)ofscenario)
SCENEINFORMATION:
• Location:EmergencyDepartmentExpecteddurationofscenario:15mins(a),20-30mins(b)Expecteddurationofdebriefing:20-30mins(a),15-20mins(b)
EQUIPMENT&CONSUMABLESPERSONSREQUIRED
• Mannequin:OnEDbed,IVAccess• Stockedairwaytrolley
(Specifically:Airwayadjuncts(OPA,NPA))• O2andselectionofmasksincl.NRB• Monitoringequipment(SpO2,ECG,NIBP)• Syringes,flushes,IVfluidandgivingsets• Simulateddrugs(Salbutamol,Ipratropium,
Aminophylline,MagnesiumSulphate,Antibioticsasperlocalguidelines)
• Bloodbottles,culturebottles,requestforms• Observationchart,medicalnotepaper,drugchart• Stockedcrashtrolley• Mock-upanaestheticequipment/drugs
FYTraineetoleadscenarioEDstaffmemberasassistantMedicalRegistrar(Ifrequested)ITURegistrar(Ifrequested)
PARTICIPANTBRIEFING:(TOBEREADALOUDTOPARTICIPANT)
1. Scene-setting: Recognition and initial management of the acutely unwell patient are essentialskillstodevelop during FY training.Today wewould like one of you to assess a patient in theEmergency Department who has been brought in by ambulance. Please assess the patientmethodicallyandtreattheproblems/symptomsthatyoufind.
2. Assistance: An assistantwill be present as the scenario begins (facultywill tell youwho this isandwhatexperiencetheyhave).Ifother(appropriate)helpisneededatanystage,askforit(thefacultywillletyouknowhowtorequestit).
3. The scenario will run until a natural conclusion, after which we will regroup to discuss thescenario and any related subjects that the group raises. This is not a test of the person whoparticipatesinthescenarioandtheywillnotbejudgedinanywayontheirperformance.
4. Wemay then move back to the manikin again for the next steps in the management of thepatient,followedbyafurtherdiscussionofanymattersthatarise.
FoundationProgramme>Scenario7
Version9–May2015 4 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
‘VOICEOFMANIKIN’BRIEFING:
Your name is Keith (Karen) Williams. You are a 29 year old hairdresser. You suffer from asthma andusuallytakeblueandbrowninhalers.Youhavehadoneprevioushospitaladmissionbecauseofasthma,buthaveneverbeentoITU.Youhavenoothermedicalhistoryandnoallergies.Youdonotsmoke.
Today your breathing has been getting worse for 3 hours and you have used all your remaining blueinhaler. You are initially very short of breath and speak in short sentences. You quickly deteriorate andmanagetoonlyspeaksinglewordsatatime. Ifpromptedbythefaculty,youwillbecomeexhaustedanddrowsy.
INSCENARIOBRIEFING:
MrKeith(MissKaren)Williamsisa29yearoldhairdresserwhohasahistoryofasthmawhogotshort ofbreathafewhoursagoanddidn’timprovewithuseofusualinhalers.Colleaguescalledanambulance.
PleaseroleplayanEmergencyDepartmentnurseorFY1doctorasdirectedbythefaculty.PleaseassisttheFYdoctorwhocomestoassessthepatientintheEmergencyDepartment.
Ifasked,telltheFYdoctorthatthepatienthasnootherpastmedicalhistory,takesblueandbrowninhalersforasthmaandhasnoallergies.
ADDITIONALINFORMATION:
The main focus of the first part of this encounter is the timely recognition of features of life-threateningasthma.
If the participant doesn’t recognise this and treat quickly according to BTS guidelines then the patientshould deteriorate, however, thismaymake the scenario too complex for some participants tomanage.Instead,themedical / ITU senior medical staff may arrive to continue care or the faculty could chooseto pause for adiscussionandthencontinuewithanotherparticipantmanagingthefurtherdeterioration.
If the participant is doing really well and faculty wish to expand the clinical challenge, then the patientcould deteriorate before the senior medical staff arrive. The participant should then expand thetreatmentsbeingadministered.Theyshouldalsobepreparedtoassistthecriticalcareteamifrequested.
FoundationProgramme>Scenario7
Version9–May2015 5 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
CONDUCTOFSCENARIO
A:Clear,speakinginshortsentencesB:RR36,SpO294%on21%/96%on15LO2,widespreadwheezeC:HR130ST,BP130/90,CRT3secD:Eyesopen,PERL3mmE:Norash,temp36.4oC
ABCDEAssessmentO2facemaskECG+NIBPmonitoring.RecogniseAcuteSevereAsthmaRxBTSGuidelines
-Salbutamol-Ipratropium-Steroids
• Seniorsnotpresentinitially• Reassess,giveMagnesium,
discussandthenstartAminophylline.ContinueSalbutamol
• DiscusswithCriticalCareandfollowtheiradvice
• Deterioration–near-fatalasthma:• GiveallBTSdrugs.A:ClearB:RR50,Silentchest,SpO285%C:HR140,SinustachycardiaD:Eyeshalfclosed,notspeaking
• ITUteamarrives:assistwithintubation• TensionPneumothoraxdevelops,hardtobag,SpO281%,HR160ST,BP80/50
• Improveswithneedledecompression.
Scenarioendwithappropriateseniorteammembersintervene,plansmade,noteswrittenandaccompanypatient.
INITIALSETTINGS
NORMALDIFFICULTY
HIGHDIFFICULTY
EXPECTEDACTIONS
RESOLUTION
• MedicalRegistrararrivesearly,
ensuresMagnesiumgiven,Aminophyllineprescribed
• Patientimproves
LOWDIFFICULTY
INTIALABG:pH7.34pO212pCO24BE-3Lact1.4CXR:NormalECG:SinustachycardiaABGAfterDeterioration:pH7.34pO29pCO25.6BE-4Lact1.4BLOODS:WCC10,othersalsonormal
RESULTS
Recognitionofprogressivedeteriorationandfeaturesoflife-threateningasthmaContactcriticalcareteamContinueBTSGuidelinetreatment:ConsiderMagnesiumSulphateand/orAminophyllineifnotalreadygiven.Gethistoryre:Theophylline
EXPECTEDACTIONS
A:Clear,speakinginshortsentencesB:RR40,SpO292%on21%/94%on15LO2,widespreadwheezeC:HR140ST,BP130/90,CR3secD:Eyesopen,PERL3mmE:unchanged
DETERIORATION
A:Clear,speakinginsinglewordsB:RR48,SpO290%on15LO2,widespreadwheezeC:HR140ST,BP90/50,CRT3secD:UnchangedE:Unchanged
FURTHERDETERIORATION
FoundationProgramme>Scenario7
Version9–May2015 6 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
DEBRIEFING
POINTSFORFURTHERDISCUSSION:
Recognitionofsignsofacutesevereasthma,life-threateningasthmaandnear-fatalasthmaTime-criticaladministrationofmedicationsasperBTSguideline(reviewguideline)RecognitionofseverityofillnessandappropriatecallforseniorassistanceAppropriatedirectionofjuniormedicalteammembers/nursingteamreurgencyoftreatmentandsignsofdeterioration
DEBRIEFINGRESOURCES
1.BritishGuidelineontheManagementofAsthma,aNationalClinicalGuidelineavailableathttp://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf
2.BTSquickreferenceguideavailableathttp://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/qrg101%202011.pdf
FoundationProgramme>Scenario7
Version9–May2015 7 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
INFORMATIONFORPARTICIPANTS
KEYPOINTS:
Earlyrecognitionoflife-threateningasthma.Recognisesignsofdeteriorationandinvolveseniorsearly–asthmastillkills!Continuetotreataggressivelyasperguidelineswhilewaitingforsupport.
RELEVANTAREASOFTHEFOUNDATIONPROGRAMMECURRICULUM
1Professionalism
1.4TeamWorking:• Demonstratesclearandeffectivecommunicationwithintheteam
1.5Leadership:• FY2demonstratesextendedleadershiprolebymakingdecisionsanddealingwith
complexsituationsacrossagreaterrangeofclinicalandnon-clinicalsituations
7Goodclinical
care
7.5Safeprescribing• Prescribesdrugsandtreatmentsappropriately,clearlyandunambiguouslyin
accordancewithGoodPracticeinPrescribingMedicines(GMC,2008)• UsestheBNFpluspharmacyandcomputer-basedprescribing-decisionsupportto
accessinformationaboutdrugtreatments,includingdruginteractions• Performsdosagecalculationscorrectlyandverifiesthatthedoseisoftherightorder• Choosesappropriateintravenousfluidsasvehiclesforintravenousdrugsand
calculatesthecorrectvolumeandflowrate• Prescribesoxygenappropriatelyincludingtopatientswiththeriskofcarbondioxide
retention• Relatesprescribingactivitytoavailableprescribingguidelines/auditdataegantibiotic
usage7.7Infectioncontrolandhygiene• Demonstratescorrecttechniquesforhandhygienewithhandgelandwithsoapand
water• Takesappropriatemicrobiologicalspecimensinantimelyfashion• Followslocalguidelines/protocolsforantibioticprescribing
7.9Interfacewithdifferentspecialtiesandwithotherprofessionals• Understandstheimportanceofeffectivecommunicationwithcolleaguesinother
disciplines
FoundationProgramme>Scenario7
Version9–May2015 8 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
8Recognitionand
managementoftheacutelyill
patient
8.1Promptlyassessestheacutelyill,collapsedorunconsciouspatient• UsesAirway,Breathing,Circulation,Disability,Exposure(ABCDE)approachto
assessingtheacutelyunwellorcollapsedpatients• UsestheGCSorAlert,Voice,Pain,Unresponsive(AVPU)toquantifyconsciouslevel• Investigatesandanalysesabnormalphysiologicalresultsinthecontextoftheclinical
scenariotoelicitandtreatcause• Usesmonitoring(includingbloodglucose)toinformtheclinicalassessment• Askspatientsandstaffappropriatequestionstoprioritisecare• Seeksseniorhelpwiththefurthermanagementofacutelyunwellpatientsboth
promptlyandappropriately• Summarisesandcommunicatesfindingstocolleaguessuccinctly• Appropriatelycommunicateswithrelatives/friendsandofferssupport
8.2Respondstoacutelyabnormalphysiology• Formulatestreatmentplaninresponsetoacutelyabnormalphysiologytakinginto
accountotherco-morbiditiesandlong-termconditions• Administersandprescribesoxygen,fluidsandantimicrobialsasappropriate(seeGood
ClinicalCare:SafePrescribingandInfectionControl)• Recogniseswhenarterialbloodgassamplingisindicated,identifiesabnormalresults,
interpretsresultscorrectlyandseekssenioradvice• Plansappropriateactiontotrytopreventdeteriorationinvitalsigns• Reassessesillpatientsappropriatelyafterstartingtreatment• Recognisestheindicatorsforintensivecareunitreviewwhenphysiologyabnormal
8.3Managespatientswithimpairedconsciousness,includingseizures• Assessesconsciouslevel(GCSorAVPU)• Treatsongoingseizures• Recognisescausesofimpairedconsciousnessandseizuresandseekstocorrectthem• Recognisesthepotentialforairwayandrespiratorycompromiseintheunconscious
patient(includingindicationsforintubation)• Understandstheimportanceofsupportivemanagementinimpairedconsciousness• Seeksseniorhelpforpatientswithimpairedconsciousnessinanappropriateand
timelyway
11Investigations
11.1Investigations• Requestsinvestigationsappropriateforpatients’needsinaccordancewithlocaland
nationalguidancetooptimisetheuseofresources• Seeksout,recordsandrelaysresultsinatimelymanner• Plans/organisesappropriatefurtherinvestigationstoaiddiagnosisand/orinformthe
managementplan• Providesconcise,accurateandrelevantinformationandunderstandsthediagnostic
questionwhenrequestinginvestigations• Understandswhatcommontests(Table1)andproceduresentail,thediagnostic
limitationsandcontraindications,inordertoensurecorrectandrelevantreferrals/requests
• Interpretstheresultscorrectlywithinthecontextoftheparticularpatient/presentatione.g.plainradiographyinacommonacutecondition
• Prioritisesimportanceofinvestigationresults
FoundationProgramme>Scenario7
Version9–May2015 9 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
DEBRIEFINGRESOURCES
1.BritishGuidelineontheManagementofAsthma,aNationalClinicalGuidelineavailableathttp://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf
2.BTSquickreferenceguideavailableathttp://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/qrg101%202011.pdf
FoundationProgramme>Scenario7
Version9–May2015 10 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
PARTICIPANTREFLECTION:
Whathaveyoulearntfromthisexperience?(Pleasetrytolist3things)
Howwillyourpracticenowchange?
Whatotheractionswillyounowtaketomeetanyidentifiedlearningneeds?
FoundationProgramme>Scenario7
Version9–May2015 11 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
PARTICIPANTFEEDBACK
Dateoftrainingsession:...........................................................................................................................................Professionandgrade:...............................................................................................................................................Whatrole(s)didyouplayinthescenario?(Pleasetick)
Primary/InitialParticipant
SecondaryParticipant(e.g.‘CallforHelp’responder)
Otherhealthcareprofessional(e.g.nurse/ODP)
Otherrole(pleasespecify):
Observer
StronglyAgree
Agree Neitheragreenordisagree
Disagree StronglyDisagree
Ifoundthisscenariouseful
Iunderstandmoreaboutthescenariosubject
Ihavemoreconfidencetodealwiththisscenario
Thematerialcoveredwasrelevanttome
Pleasewritedownonethingyouhavelearnedtoday,andthatyouwilluseinyourclinicalpractice.Howcouldthisscenariobeimprovedforfutureparticipants?
(Thisisespeciallyimportantifyouhavetickedanythinginthedisagree/stronglydisagreebox)
FoundationProgramme>Scenario7
Version9–May2015 12 Editor:DrAndrewDarbySmithOriginalAuthors:Author:LWilliamson,JBowen,NFeely
FACULTYDEBRIEF–TOBECOMPLETEDBYFACULTYTEAM
Whatwentparticularlywellduringthisscenario?Whatdidnotgowell,oraswellasplanned?Whydidn’titgowell?Howcouldthescenariobeimprovedforfutureparticipants?
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