If I only knew then what I know now… Presented by: Cynthia G. Cunningham, MSN, RN Southwestern Virginias Regional Clinical Simulation Centers.

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?