University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Leadership: Triage/Prioritization (Part 1) Overview

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1 Title: To cite this reference: Triage/Prioritization (Part 1 of 2) University of South Dakota Simulation Scenario Leadership: Triage/Prioritization (Part 1) Overview Target Group: Second Year Concept: Leadership Nursing Students Serfling, J. & Warren, D.(2012). Simulation scenario; Leadership: Triage/prioritization (part 1 of 2). Unpublished manuscript., University of South Dakota at Vermillion. Time Allotment (each simulation is designed to be run in a two hour block of time which equals four clinical hours): Prep: Designed to take approximately four hours (see preparation requirements). Prebriefing: Campus specific. Should be shorter than debriefing for second year nursing students. Simulation: Approximately 30 minutes. Debriefing: Campus specific. Should be longer than prebriefing for second year nursing students. If the simulation episode runs less than two hours consider running the simulation again, create concept maps, create teaching plans, perform web quests to further understanding or other activities you feel would be beneficial to the students learning. DocuCare Information: This is a prioritization/triage scenario in which the RN is assigned to three patients and must employ clinical reasoning in the prioritization of their assessment and care.

2 AACN Essentials: II, VI, VII, VIII, IX University of South Dakota Curriculum Alignment Population: Elderly males and middle age female Leadership: Triage/Prioritization (Part 1) 2 Concepts Leadership Transition into Practice Quality Improvement (Part 2) Exemplar Prioritization Resource Management Knowledge Skills Objectives and Outcomes Area Scenario Objectives Course Outcomes Based on assessment findings, implement appropriate care for each patient. Work with healthcare team to meet patient needs and delegate correctly within scope of practice. 1.1, 3.2, , 3.2, 5.2 Attitudes Recognize when a patient is unstable and intervene appropriately. Appreciate need and importance of accurate prioritization when treating multiple patients. 1.1, 3.2, 5.2 Student Preparation Prerequisite assignment (the following information should be sent to the students prior to the scheduled simulation) Students are expected to bring their laptop, drug book, primary text and completed prep to simulation. The following prep is for both Parts I and 2 of this simulation. Triage Priority 1&2_Student Prep

3 Leadership: Triage/Prioritization (Part 1) 3 Simulation Setup Scenario Setting: Setting: Med-Surg unit Time of day of scenario: 0830 All three patients/rooms separated by curtains/walls if possible and signs for each room (#1, #2, and #3) Roles for Students (same for all 3 patients) Primary nurse Secondary nurse Recorder Observer(s) Rapid Response Team Member Student Names (Faculty)

4 Leadership: Triage/Prioritization (Part 1) 4 Patient #1 Manikin Settings: Initial Vital Signs Pulse: 170 Blood pressure: 105/68 Pulse ox: 72% with O2 on at 3 L Respiratory rate: 24 Temperature: 99.4 F Cardiac rhythm: Atrial fib Lung sounds: Coarse with crackles bilat Bowel sounds: Bowel sounds + Other: Left hip incision draining, saturated dressing with sanguineous fluid Equipment List O2 tubing Saline lock in manikin arm ID band Dressing to left hip (saturated with yellow fluid) Non-rebreather mask Telemetry Patient Condition Clothing: Hospital gown Props: Moulage: Documents for Patient #1 Lab sheet Blank MD order sheet Dressing to left hip (saturated with yellow fluid) Graying of lips (Cyanosis) Medication Dosage Route Lasix 40 mg IV Concentration Package

5 Leadership: Triage/Prioritization (Part 1) 5 Patient Demographics Last Name: Smith Patient Background Patient 1 First Name: John Gender: Male Age: 85 Ht: 5 4 Wt: 135 lbs Ethnicity: Caucasian Religion: Lutheran Language: English English Proficiency: Yes Other: Widowed, lives alone at home. No children. Niece and nephew DPOA. History of present illness: Fell at home three days ago and had left hip fracture. Surgical repair of left hip two days ago. Primary Medical History Central nervous system Cardiovascular CHF Pulmonary COPD, smoker 1 PPD x 60 years Renal/Hepatic Some incontinence problems x three years Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Widowed Other DM (orally controlled) Medication allergies NKDA Reaction: Food/other allergies Reaction:

6 Leadership: Triage/Prioritization (Part 1) 6 Patient #2 Manikin Settings: Initial Vital Signs Pulse: 68 Blood pressure: 135/88 Pulse ox: 99% on room air Respiratory rate: 18 Temperature: 97.8 F Cardiac rhythm: Sinus rhythm Lung sounds: Clear Bowel sounds: Present x 4 quad Other: Equipment List ID band Foley cath with 200 ml clear urine Syringes Insulin drip Patient Condition Clothing: Hospital gown Props: Moulage: Documents Lab sheet Medication Dosage Route Concentration Package Insulin drip (regular) with 1 unit/cc NS at 100 cc/hr

7 Leadership: Triage/Prioritization (Part 1) 7 Patient Demographics Last Name: Kelley Patient Background Patient 2 First Name: Maria Gender: Female Age: 40 Ht: 5 10 Wt: 190 lbs Ethnicity: Caucasian Religion: Does not practice Language: English English Proficiency: Yes History of present illness: Admitted with DKA yesterday following an illness at home. Blood sugars and status now stable. Primary Medical History Central nervous system Cardiovascular Hypertension Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Married with children, denies ETOH or tobacco use Other Type I DM since age 10 Medication allergies PCN Reaction: Rash Food/other allergies Reaction:

8 Leadership: Triage/Prioritization (Part 1) 8 Patient #3 Manikin Settings: Initial Vital Signs Pulse: 88 Blood pressure: 126/84 Pulse ox: 91% on room air Respiratory rate: 22 Temperature: 98.0 F Cardiac rhythm: SR Lung sounds: Scattered wheezes and crackles throughout Bowel sounds: Present x 4 quad Other: Patient Condition Clothing: Hospital gown Props: Moulage: Documents Medication Dosage Route Concentration Package Equipment List ID band Syringes Saline lock

9 Leadership: Triage/Prioritization (Part 1) 9 Patient Demographics Last Name: Wilson Patient Background Patient 3 First Name: Henry Gender: Male Age: 78 Ht: 5 4 Wt: 185 lbs Ethnicity: Caucasian Religion: Lutheran Language: English English Proficiency: Yes History of present illness: Admitted for acute exacerbation of COPD three days ago. Anxious at times. Short of breath with activity. Preparing for discharge. Primary Medical History Central nervous system Cardiovascular Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Other Medication allergies Food/other allergies MI four years ago, hypertension, left sided CHF COPD. Smoked two packs/day x 35 years, quit 10 years ago. Married with three adult children Reaction: Reaction:

10 Prebriefing Leadership: Triage/Prioritization (Part 1) 10 Give students the opportunity to discuss their feelings and fears (can use the round table approach) and then have discussion. The following are suggested discussion questions for this scenario: 1. If you have just received reports on your three patients for the day, how will you decide who you will see/assess first? (Have students pair up to discuss answer, then ask a few groups to respond.) 2. Discuss leadership and management of patients. 3. What makes you most nervous about having three or more patients at a time and having to prioritize? 4. What should you do if you have two patients (both deteriorating) at the same time? Have students discuss their prep in small groups of two to three students, then pick out key points to discuss. The above items are listed to assist faculty in leading a prebriefing discussion with students. Feel free to use some or all of the items depending on the needs of the student group.

11 Scenario Leadership: Triage/Prioritization (Part 1) 11 Change of shift report to students: To be read to all students (by instructor) prior to start of simulation. Students should take notes like they would when receiving report. Patient #1: John Smith is an 85-year old male admitted for Dr. Lee. He fell at home. He has a history of COPD, smoked one pack per day for 60 years, CHF and DM. He had surgery two days ago for the left hip fracture. We are to change the dressing daily and PRN. The incision site is slightly pink, edematous, and draining sanguineous drainage. I changed the dressing once in the night. They stopped his IV fluids yesterday. He is saline locked. The patient gets QID blood sugar checks. I checked him in the night because he felt kind of sweaty and didn t talk to me much, but his sugar was 110. I checked his vitals at Temp 99.0, HR 98, R-20, BP 100/65, O2 sat 91 & on 1 liter, I bumped up his oxygen to 3 liters at that time. His lung sounds are coarse. As for as orientation goes, he was A & O x 3 last night but really hard of hearing. Any questions before I go? Patient #2: Maria is a 40 year old patient. She was admitted two days ago with DKA. She has a history of poorly controlled DM-Type 1. Apparently her blood sugars have been poorly controlled over the last week when she had a GI bug. Upon admission to the hospital her blood sugar was 530. She is A & O x 3. Lung sounds clear, bowel sounds positive. She has an IV of NS at 100 cc/hr as well as an insulin drip (regular insulin) at two units/hr (which is two cc/hr). She has a Foley cath draining clear yellow urine. Her vital signs have all been fine, and her sugars have been primarily in the 200 s. Her blood sugar right before report was 257. Patient #3: Henry is a 78-year-old male patient of Dr. Stars. He was admitted three days ago with COPD exacerbation. He was on oxygen at two liters initially, but has been weaned off. He complains of shortness of breath with activity. He is A & O x 3. Very particular about things. Lung sounds have crackles and wheezes bilaterally. Pedal pulses palpable, maybe some trace edema on his lower extremities. Pulmonary rehab saw him yesterday and recommended he be on O2 at 2 liters at home with activity. I believe the plan is to discharge him today and he wants to go home. Any questions?

12 Leadership: Triage/Prioritization (Part 1) 12 Timing Patient actions live faculty Expected interventions May use the following cues: Approx. 5 minutes Henry (pt #3) puts call light on. States to nurse, The doc came in this morning, said I am doing pretty good. I want to go home. Can you get the paperwork going and take this IV out? Henry s VS- HR-88 BP- 126/84 RR- 22 Sp O2-91% on room air Temp F Nurses are looking at their report sheets and deciding who to go see first. Nurses explain to Henry that they need to review MD orders and complete paperwork, as well as assess their other patients first. Removal of saline lock can wait. Nurses do Henry s assessment and vital signs. Role member providing cue: While students are in the room, have Maria s light go off. Approx. 10 minutes Maria (Pt #2) puts call light on. I m hoping you can request some breakfast for me. Can I get some orange juice, cinnamon roll, and grapes? Maria s VS: Temp F HR- 68 RR- 18 BP- 135/88 SpO2-99% on room air Nurses go in to assess Maria and see what she needs. Nurses do teaching about diabetic diet and why her requests are not appropriate. Maria: The night nurse said I will need some potassium today. Why would I need that? What could happen if I didn t get that IV potassium? Nurses look at lab sheet and note K of 3.2. Nurses explain connection between low K and dysrhythmias.

13 Leadership: Triage/Prioritization (Part 1) 13 Approx. 15 minutes John (pt #1) is found to be lethargic and minimally responsive. HR- 170 BP- 105/68 RR- 24 SpO2-72% with O2 at 3 L Temp- 99.4% F Lungs: coarse crackles Bowel sounds positive Nurse s aide (faculty person) comes in and states, Your patient Henry is dressed and wants to leave. Do you have his discharge stuff ready? Rapid Response Team (faculty person) comes in and asks what is going on then gives following verbal orders: 1) Stat CXR 2) Stat EKG 3) Lasix 40 mg IVP x1 now 4) Draw ABGs 5) Transfer to ICU Nurses go in to assess John. Nurses note change in John s status,as well as change in VS from what night nurse reported. Nurses apply nonrebreather mask. Nurses put patient on telemetry. Nurses call Rapid Response Team. Nurses possibly/may choose to check blood sugar. Nurses know that John is their priority and the other two patients must wait. Nurses take off orders on blank MD sheet. (Simulation ends after nurses obtain and write down orders).

14 Leadership: Triage/Prioritization (Part 1) 14 Debriefing Start by asking students about their feelings/thoughts related to the experience. It is alright to let the students lead the discussion at first. Utilize the questions below at your discretion. Debriefing / Guided Reflection Questions for this Simulation: 1. What was it like when you were trying to get organized for the shift and you already had a patient call light going off? 2. When you went to see Maria, how comfortable were you doing teaching about a diabetic diet? How comfortable were you teaching her about the potassium being low? What would you have done if you didn t know the answer to her question? 3. How did you feel when you went into John s room and realized he wasn t doing well? 4. How did you prioritize your interventions for John? If you had to do over, what would you have done differently and why? 5. If you called for a Rapid Response, what led you to do that? If you did NOT call for a Rapid Response, why didn t you? 6. What do you think was going on with John medically when he deteriorated? 7. How did you feel when you learned that Henry was dressed and waiting for you to do his discharge paperwork? How else could you have handled that? 8. If you could repeat this scenario and had a nurse s aide available, what could you have delegated to him/her to help you? 9. If you could repeat this scenario, what do you think the nursing team should have done differently? 10. How would bedside reporting have changed this scenario? Final thoughts? The above items are listed to assist faculty in leading a debriefing discussion with students. Feel free to use some or all of the items depending on the needs of the student group.

15 Leadership: Triage/Prioritization (Part 1) 15 Supporting Documents Forms Patient Chart Information/Forms Triage Priority 1_Charts Script/Roles No script required for primary or secondary nurse. If non-faculty/students play the patient roles, they should be given a copy of the script. Recommendations For Online Use This simulation would be difficult to perform in the mobile simulation unit. A video-taped version of the simulation (performed in a simulation lab) could streamed to distance students. Students at a distance could participate in the pre-briefing and debriefing sessions using webinar.

University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Leadership: Triage/Prioritization (Part 2) Overview

University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Leadership: Triage/Prioritization (Part 2) Overview Title: To cite this reference: Triage/Prioritization (Part 2 of 2) University of South Dakota Simulation Scenario Leadership: Triage/Prioritization (Part 2) Overview Target Group: Second Year Concept: