Facilitation Interns Acquisition of Medical Knowledge and Core Skills through Experiential Learning Raquel Belforti, DO, Kevin Hinchey, MD Reham Shaaban, DO Mihaela Stefan, MD Baystate Medical Center Tufts University School of Medicine
Agenda Discussion of the orientation experience Review the role of experiential learning for new interns orientation Describe the Baystate Internal Medicine Program Model
Objectives 1. Understand the advantage of an intensive two weeks training to improve rapid acquisition of clinical competence in early internship 2. Recognize the benefits of using scenario based simulation training during intern orientation 3. Gain the skills necessary to re-organize initial month of internship to facilitate interns acquisition of the basic skills needed to manage an unsupervised situation and reduce risks to patients
Discussion #1 Intern orientation content Goals for the first month
Intern Orientation
National Orientation Data Survey of Program Directors n= 109 88% University Affiliated
Discussion #2 Methods/types of teaching activities
Perfect World Medical Knowledge Professionalism Communication Practice-based Learning System-based Practice
Perfect World Medical Knowledge Professionalism Patient Safety Communication Practice-based Learning System-based Practice
Discussion #3 What is experiential learning? How is it different from the see one, do one teach one approach
Experiential learning Experiential Learning is the process of making meaning from direct experience, the connecting of learning to real life situations "For the things we have to learn before we can do them, we learn by doing them Aristotle
Patient Care Core competencies Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice
Discussion #4 Experiential learning: why simulation has become so important
SIMULATION
Discussion #5 Video Based on our video scenario, we will discuss: Simulation as an Educational Instrument Intern perspective/experience Simulation as an Evaluative Instrument Faculty/Program perspective with regards to assessment and learning: Diagnosing the learner
Goals of BMC Curriculum for Interns - First month To help interns to gain the necessary competencies and confidence to manage unsupervised critical situations To enforce the emergency and safe care practices and survival skills as required to begin a medical residency Simulation based training will be used to orient and guide learners through the basics of fundamental and safe medical practice for inpatient care To reduce risk to patients To allowed the educators to identify earlier the strong and the weak residents
Baystate Curriculum Pre-test Confidence questionnaire Boot camp binder (literature for self-study, study, pre-test for each session) 2 week simulation course of 2 hours/day 8 cases Chest pain SOB Hypotension Mental status changes Nursing and ancillary staff support Checklists Debriefing EKGs, Quizzes, progress notes, H&P, discharge summaries, handovers Post test
Test results Bootcamp Knowledge Assessment Test 100 % correct answers 80 60 40 20 0 Pre 1 Test Post Test
Discussion #6 Costs and Benefits
Why use simulation for interns orientation? Enhance resident confidence Reduced risk to patients Better/more efficient training Active vs. passive learning More degrees of freedom (redo, errors ok, pause time, part tasks)
Simulators Come in Many Varieties Standardized patients (OSCE) Screen based simulators (virtual patients, pharmacology and physiology simulations) Electronic and non-electronic mannequins Actors: patients, staff, family members
Why use simulation? Safety Standardization Efficiency
Barriers Faculty development Implementation costs Resource support Scheduling time Not Very Efficient Must Plan Ahead Difficult to Develop Techno-phobia Status Quo is Easier
Conclusion Impact on Interns Impact on Program
Feedback from participants I I admitted a patient last night with CHF exacerbation and I knew exactly what to do We had a patient with an active GI bleed and my intern was telling me to start octreotide,, I cannot believe he knew that
Set Standards of our Program Pre-reading reading questions- Professionalism Be on time- Professionalism Working together- Teamwork Communication Asking for help- Patient safety Debriefing- Self reflection
Baystate Simulation Center Patient Development Form Clinical Service: INTERNAL MEDICINE Target Audience: R1 for management and R3 for teaching Lesson Title/ Scenario File Name in HPS6 Software: Hypotension secondary to Sepsis Type Teaching: Intern Nightfloat called to evaluate a patient with hypotension Date Built: 4/29 Date Last Revised: 6/16 Developer: Mihaela Stefan, Raquel Belforti Synopsis of Scenario: 74 y male NH resident, admitted 3 days ago for syncope, off monitor x 24 hours. Nurse calls the intern because patient is hypotensive, febrile and obtunded. It will be a case of sepsis secondary to UTI Foley catheter was left by mistake in place. Hospital course from admission: 74 y male, admitted 3 days ago after a syncopal episode, no clear cause identified. -Carotid Doppler, head CT, Hip X-Ray are negative -Echocardiogram done today- results pending -Telemetry monitor discontinued 24 hours ago. -No other episodes in the hospital, still some dizziness when standing. Past Medical History: DM COPD CAD s/p PCI to LAD many years ago BPH Medication at home: Atrovent, Lisinopril, Atenolol, Glipizide, Trazodone Soc Hx: Lives with wife. Quit Tobacco 20 years ago (40pk/hr), +Etoh 1 glass wine with dinner daily ALL: NKDA Medication: Lovenox 40 Units sc, Atrovent prn, Lisinopril 20 mg daily, Atenolol 25 mg daily, Glipizide 10 mg BID, Nexium 40 mg daily, Seroquel 25 mg QHS Current review of Systems: complains of some lower abdominal pain Current Physical Examination: BP 85/60, HR 100/min, O2S 87%, RR 22/min, T 101.8, GEN: obtunded, diaphoretic, shallow breathing HEENT: PERRL, mucous membranes dry, Jugular veins flat HEART: Tachycardic, regular rhythm, no murmur LUNGS: Clear to auscultation ABD: soft, BS positive, some tenderness in hypogastrium. EXT: warm, good peripheral pulses. No edema Foley draining cloudy urine.
Current Labs: WBC 20,000, neutrophiles 85% and 20% bands Platelets 110,000 Hb 13, Na 148, K 3.3 Chlorite 104, HCO3 16, BUN 30, Cr 1.6, Glucose 340 Trop 0.01 lactic acid 5 UA specific gravity 1024, WBC 80, nitrite pos, cloudy ABG 7.33/28/60 on RA Imaging: CXR clear ECG associated with this state: sinus tachycardia Admitting Labs: WBC 10, Hb 12, Ht 43, Platelets 240, Na 142, K 3.8, Chlorite 105, HCO3 22, BUN 17, Cr 0.9, Glucose 200 PE at admission: BP 140/60, HR76/, O2 96%, lugs clear, heart regular S1, S2, abdomen normal, alert, oriented x3 Patient Name, Age, Gender: Smith Santana, Room: S2 28A Time: 10:30 PM Chief Complaint (Nurse SBAR) S: Patient is hypotensive, febrile and lethargic. B: 74 y admitted 3 days ago with syncope A: BP 85/60, HR 100/min, O2S 87%, T 101.8, obtunded. R: I need you to come to evaluate him ASAP Patient is not on the monitor if monitor is suggested, the nurse will call telemetry charge nurse for a bed, but they will not have one. The nurse can suggest to use the crash card monitor if the patient is really sick or call RRT Roles with brief description: Interns: One working team of 2 R1 will take care of the patient, one observing team will watch from outside Nurse: Respectful, initial minimally helpful; if the residents get stuck, will give suggestions. The nurse will question fluid monitoring. If the intern order antibiotic without checking allergies, the nurse will make a specific, loud comment about the risk. Materials to be used in the debriefing: Sepsis NEJM article
Learning Objectives or Assessment Objectives At the end of this session the interns will be able to: 1. Recognize an unstable patient with hypotension 2. Stabilize unstable hypotensive patient 3. List differential for shock a. Distributive (septic shock) b. Cardiogenic c. Obstructive d. Hypovolemic (hemorrhagic) 4. Recognize and implement early goal directed therapy for septic patients a. IVF b. Cultures c. Appropriate antibiotics 5. Recognize medical error of Foley induced Urosepsis 6. Order set for sepsis
Instructor s Observations/Checklist of Critical Actions Recognition and initial work-up of hypotension Assessment of patient s instability (hypotension) Physcial exam (other signs hypoperfusion) Starts IVF Assures Adequate IV access Head of the bed down Cardiac Monitor EKG Labs, cultures Reviews history and medication list Recognizes and Management of Sepsis Continues fluids When not responsive to IVF, starts vasopressors, calls ICU Gets blood cultures Reviews possible sources of infection (urine, lungs, abdomen) Starts broad spectrum antibiotics Calls R3 for help Differential Diagnosis Differential for Hypotension Distributive- septic shock Cardiogenic Hemorrhagic Differential for possible etiologies of infection Urine Lung Abdomen Blood Teamwork With Nurse Ask R3 for help Calls ICU resident Error No recognize septic shock No recognize foley as culprit for infection Does not start broad spectrum antibiotics No ask allergies before give antibiotics