Las Vegas, Nevada Theresa Mottes, RN, CDN High-Definition Simulation for CRRT Nursing
Objectives Simulation overview Simulation in the Medical Profession Simulation in Nursing Simulation in CRRT
Simulation History WW I - first documented use of Simulators for training 1909 Training Rig
Aviation Industry Flight Simulator
Advancements in Simulation Technology Visual Systems to Motion Systems to Multi dimensional Including sound, motion, visual sensory cues
Simulation in Healthcare 1960 Resusci Annie Mouth to Mouth Spring Chest The Harvey Mannequin (University of Miami) Physical aspects of the cardiology examination 1986 NIH Virtual Human Project Anatomically correct 3 dimensional human body Mid-Late 1990 Computer Based Medical Simulators K. Kunkler Int J Med Robotics Comput Assist Surg 2006; 2: 203 210.
Simulators
Simulation Planning Target Audience Determine Objectives/Goal Outcomes Metrics Measuring time points Simulator Modifications Access/Machines/Tubing
Pre-Simulation Scenarios Content/Focus Evaluation/Assessment Tool Flow Process Desired Process Alternate Process Incorrect Process
Scenario Flow Diagram VS at Baseline CRRT Access/Return Pressure Alarm Baseline VS: HR 145; BP 92/73 (85) SpO2 98 % Incorrect Process Alternate Process Desired Process Incorrect Process Identifies CRRT alarming Calls for Charge Nurse to Assist Identifies that the CRRT machine is alarming Citrate & Calcium NOT stopped/paused Call the CACN RN Stops Calcium & Citrate Infusions Repositions patient & restart machine See Incorrect Flowchart VS Changes: HR 160; BP 72/73 (65) SpO2 98 % CACN RN (via the phone) walks the RN through the desired process CRRT machine alarms Flushes catheter & determines catheter patency adequate for BFR VS Changes: HR 130; BP 81/45 (72) Continues to restart machine (may choose all the other interventions) 4-5 minutes VS Changes: HR 55; BP 42/33 (40) SpO2 88 % Recognizes catheter will NOT tolerate BFR. Reverses lines Citrate & Calcium Stopped/Paused Restarts machine CRRT machine alarms Recognizes catheter will not tolerate Decreases the BFR Obtain patient I Ca & treat appropriately VS slowly improve RN and Nephrology discuss new BFR Citrate & Citrate rates changed to reflect new BFR Discuss catheter (TPA, Change)
Staff Expectations Dress/Attire Come to work attire Complete prior material Pre-assessment/education Simulator treat as patient Allow time to acclimate to the environment
Role Assignment Primary RN Primary Technician Secondary Responder Charge Nurse Confederates
Simulation Sessions Setting Environment reflects work setting Pre-determine the length of scenario Event or Time Know your audience Allow scenario to develop Facilitator and Simulator
Simulation Debriefing Debrief Process Review key components of scenario Symptoms Pathophysiology Treatments/Skill Review Education What went well? Didn t go well? What would you do different Critique performance
Simulation in Acute Setting (CRRT) Background Patient/year ~ 30 patient CRRT treatment days/year ~ 350 days Patient age ~ 163 mos (13 y) (1 day 23 years) Patient weight ~ 37 Kg ( 0.9 Kg 154 Kg) 2008 - Transitioned Nursing Model Dialysis to Critical Care
Program Outcome Metrics Filter Life Unplanned vs. Planned Filter Changes Patient Care Associated vs. Non-Patient Care Associated Comfort/Knowledge Assessment
Educational Needs Assessment Survey Self Reported Comfort Scores (1-5) Patient Safety Reports
Annual Education: The Process ~ 78 RN (Pilot) 2 RN/session (90 minutes) Each scenario last no more than 10 minutes Card w/ Patient Information All scenarios started with programming the machine Debrief after each scenario
Filter Life Sim Training
Filter Life Filter Life Comparison* Pre Simulation Education (n=92) Post Simulation Education (n=144) p-value# All periods 35.5 (15.2, 63.1) 59.4 (22.2, 76.4) 0.01
Unplanned vs. Planned Filter Changes
Basic Education/Orientation Ideal Simulation Topic Catheter infection (BSI) Cardiac arrhythmias Electrolyte imbalances Fluid Balance/Removal Patient Code Clotting Filters Pressure Alarms
Multidisciplinary Simulation Communication Scenarios RN to RN CDT to RN CDT to CDT RN to MD Staff to Family Dialysis Rounds
Other Simulation-Like Techniques 3 D second life training Avatar Environments Video simulations
Questions?