Introducing FAST scans into the Simulated Learning Environment

I really enjoyed putting the EDUS2  together. The challenge now was to integrate it into the simulated learning environment. I jointly run a workshop called twisted advance life support with the Director of Emergency Medical Training. Its a two hour multidisciplinary scenario based education session run twice a month. The scenarios were complex in nature based on emergency resuscitation area type presentations. The learning objectives are based around the principles of crisis resource management and the Australian advance life support guidelines. The participants are Emergency Registrars  and Emergency Nurses.

In consultation with the Deputy Director of the Emergency Department we decided to use the EDUS2 in one of our scenarios. The scenario consisted of a male patient presenting with abdominal pain and deteriorating to cardiac arrest. The diagnosis was a dissecting aortic aneurysm . Five rfid tags were placed under the skin of the manikin; pelvic, abdominal, perihepatic, perisplenic and  pericardial. During the manikin familiarisation the EDUS2 was introduced so the participants had an idea of the functionality and the limitations.

The EDUS2 was used during the scenario and the participants used it is making their diagnosis. During the debrief it the participants discussed the use of FAST scans in emergency situations.

Points included:

  • How long a FAST scan should take
  • What are the advantages and disadvantages of FAST scan use
  • FAST scan interpretation
  • Positioning and placement of the probe

It was clear that there was a need for further education. Since then we have obtained a phantom fast scan trainer and the consultant group have provided both didactic and Part task trainer education. We are developing a tool to audit the participants use of the EDIS2 during simulation and have asked for regular feedback from the emergency registrars and consultants on the use of fast scans in the emergency department. We are also planning to use the EDUS2 in our paediatric trauma simulations.

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The Australian EDUS2 Project

I am a Simulation Coordinator at a small skills development centre just north of Brisbane. We run a Twisted Advanced Life Support workshop as part of the Emergency Department registrar training. The simulations have been running for about 18 months. The focused assessment with sonography for trauma scanner (F.A.S.T.) had not been used in our simulations and therefore the doctors and nurses only had exposure to it in the Emergency Department.

I found out about the EDUS2 ultrasound trainer on Twitter through @PecoraNera1 . The guys from Saskatchewan, Paul Kulyk and Paul Olszynski (www.edus2.com) have developed a trainer for using in simulation which they explain very well in their project summary:

“The Emergency Department Ultrasound Simulator (edus2TM) is a portable bedside ultrasound device that allows for the seamless integration of Emergency Department Ultrasound (EDUS) into high fidelity simulation scenarios (HFS). Trainees using the edus2 gain the opportunity to determine whether to use bedside ultrasound (indications), how to properly hold and place the probe (image generation) and finally how to assess scans (image interpretation) as displayed on the edus2 screen all within the context of an HFS scenario.” (check out their video here).

They have kindly made this available though a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License . The EDUS2 seemed like the ideal way to integrate F.A.S.T. scans into our simulations.

The EDUS2 web site had all the information I needed. The cheaper things such as the R.F.I.D. scanner and tags I ordered online. I put in a request for a disused laptop to our information division. This was very complicated for them to understand. They give their old laptops to the hospital foundation to raise money for the hospital. They had never had a request to give an old laptop to an employee for use within the hospital. They were only able to sell me a new one at a great cost. I sent a copy of the EDUS2 project description to the hospital executive director with a covering letter hoping that she might be able to get me an old laptop. The next day I got a phone saying that she was generously donating her own old laptop to the project. This saved me a lot of time and expense. The next step was to find an ultrasound probe. I then went to see the chief radiographer. She was kind enough to provide me with an old probe from an ultrasound machine that was being donated to a vets (sorry cats, dogs, roos, crocs, koalas etc).

Once I had all of the equipment it was time to put it together.

I wiped the HDD of the laptop and installed the open source operating system, Ubuntu. Then I followed the EDUS2 guide linking the software on the computer to the comprehensive ultrasound scan library that the EDUS2 guys provide. Once I had done this I tested the R.F.I.D. scanner and the tags. This all worked very well. Thanks to the excellent directions. I then enlisted the help of my friend Mark Buchanan. He is an electrician amongst other things, and all round good bloke. He gutted the ultrasound probe for me, then recreated the grey part of the probe by bending plastic gutter down-pipe and super gluing in place. We modified Olimex MOD-RFID 125 R.F.I.D. scanner so that the electromagnetic field coil was in the tip of the probe. To do this he disconnected the copper wire and re-soldered it to the circuit board. This took a few goes to ensure that the tip of the probe was the most sensitive part. The probe was then resealed with silicone and superglue to ensure that it was water proof.

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I bought a stand from the local discount supermarket for $30 and now it’s ready to go, all this for under $100. I am looking to use the EDUS2 in the next Twisted ALS and I’m planning to integrate it into other critical care simulations. I will post a video of it in action in the next week or so hopefully.

A big thanks to Paul Kulyk and Paul Olszynski for their innovation, excellent guides and philanthropy. They are presenting the EDUS2 at the 2012 Society for Academic Emergency Medicine Annual Meeting. I will be very interested to know how they get on. Follow them on Twitter @edus2sim or their contact us page .

I would also like to thank Mark Buchanan for his help in creating the probe and his expertise in electronics. I would not have been able to complete the project without him.

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Materials

  • Laptop Free
  • RFID scanner $46.73
  • RFID tags $15
  • USB cable 5$
  • Ultrasound probe Free
  • Stand $30

Total cost : $96.73

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A multi faceted approach to assessing education and processes in a clinical setting

By producing results that have had positive impact on cost savings and the quality of care, simulation is becoming widely recognized as a valuable application in the healthcare industry [1, 2]. The transfer and admission of patients from the Emergency Department to the Delirium and Falls Unit (DAFU) was identified by Luke Wainwright (Simulation Co-ordinator and Clinical nurse) and Christina Kapitsalas (Patient Quality and Safety Officer) as an area that would benefit from simulation based analysis. This was our first simulation with a multi-faceted approach. An expert panel of Christina Kapitsalas (Patient Quality and Safety), Rosemary McIntosh (Complex care Clinical Nurse Consultant), Jesse Spurr (ICU educator), Sylvia McLaughlin (Rehab Nurse Educator) and Luke Wainwright (Simulation Co-ordinator) was created with the brief of reviewing the simulation and relating the findings to their own specialities.

The scenario was based on a real patient that had been identified by the complex care Clinical Nurse Consultant as an appropriate patient for admission to the Delirium and Falls Unit. The patient was anonymised by removing the time, date, names, location and hospital number from the document. The participants for the simulation included two Emergency nurses, and two DAFU nurses. It was decided that a simulated patient should be used as we were keen to evaluate the communication between the participants and the patient. The Rehabilitation Nurse Unit Manager played the simulated patient as it was important to have an elderly care expert to exhibit the expected symptoms.

Patient history as taken by the attending medical officer:

Ninety six year old female brought in by ambulance with multiple falls and generalised deterioration over the past week. Profoundly deaf and poor eye sight unable therefore to communicate with patient. The patient daughter is not coping at home.

  • Paramedics called by daughter due to multiple falls (three falls today) over the past week with facial lacerations sustained
  • Patient has decreased oral intake, only has water with tablets and reports of increased confusion
  • Paramedic reports very poor social situation at home, both patient and daughter not coping at home
  • Haemodynamically stable en-route to hospital and not complaining of any pain but obvious facial lacerations
  • Poor historian, collateral from previous presentations
  • Currently on oral antibiotics for chest infection

Past medical history: Atrial fibrillation, congestive cardiac failure, query dementia, hypertension

Medications: Colchocaine ointment, Cholecalciferol, Folic acid, Coloxyl and Senna, Candesartan, Frusimide, Perindopril, Digoxin, Felodipine, Assasantin, Amoxycillin, Clarithromycin

Allergy: unknown

On examination:

 

  • Temperature 37.2°c, blood pressure 176/67, heart rate 85, respiration rate 32, oxygen saturations, 94% room air, blood sugar level 6.3 mmols/l
  • Glasgow coma scale 14/15 confused, moving all limbs spontaneously
  • Chest: bibasal crackles
  • Heart sounds dual, nil murmurs
  • Abdomen soft and non tender, bowel sounds active
  • Poor skin turgor and mucous membranes dry

 

Impression: Multiple falls of unknown cause, query lower respiratory tract infection need to exclude intracranial pathology. Currently clinically stable.

 

Plan:

 

  • Bloods
  • Chest x-ray
  • Electrocardiograph
  • Slow intravenous fluids
  • Analgesia
  • Review and discuss with consultant for need of computerised tomograph (CT) of head for diagnostic purposes

 

Additional note:

Patient will almost certainly need admission thus should have diagnostic CT of head.

CT head and face requested.

The expert team identified interventions that they considered would improve clinical practice, patient safety and the movement of patient around the hospital. They have been divided into two groups, Education and Process:

Education:

  • Delirium: diagnosis and management
  • Documentation
  • Patient assessment
  • Nutrition and hydration
  • Medication safety
  • Communication
    • With patient
    • With other staff
  • Structured Handover
  • Referrals
  • Falls risk
  • Pressure Area Care

Process:

  • Handover (S.B.A.R.)[3]
  • Documentation
  • Pharmacy Review
  • Fall Prevention
  • Work unit guideline and Queensland Health policy review

Recommendations:

  • Develop educational packages relevant to identified needs
  • Orientation to the appropriate documentation and algorithms used for assessment of patients.
  • Short in-service during nursing scrum and by Clinical Nurse Teacher (CNT)/Nurse Educator of primary and secondary survey and how to assess patients who are at risk of pressure sores.
  • Introduction of “drug of the month”. Relevant drug information to be emailed out on particular medications each month.
  • Pharmacists to present “on the run” in-service to nursing staff on medication safety
  • Promotion of ilearn (online learning package endorsed by (Queensland Health) package on recognition and management of deteriorating patient on line learning tool.
  • On the run in-service by CNT or Nurse Educator on appropriate referrals
  • Place SBAR handover guides by all telephones
  • Encourage staff to participate in the Recognition and Management of Deteriorating Patient Workshop
  • Promote Delirium and Falls Unit assessment tools
  • Investigate availability of low beds for use
  • Instigate audit cycle [4]
  • Review and promote the Work Unit Guideline for the transfer of patient to the ward.
  • Include identified issues in broader review of Emergency documentation.
  • Reintroduce a pharmacy review to the Emergency department

This is the first in a series of scenarios to assess and review the performance of staff and the processes used within the Hospital. It is an important first step in challenging the current model for assessing process and clinical skills. The aim is to implement a formal audit process [4] to allow us to obtain clear evidence of improved patient care from the use of simulation.

References

1.         Bender, J., R. Shields, and K. Kennally, Transportable enhanced simulation technologies for pre-implementation limited operations testing: neonatal intensive care unit. Simul Healthc, 2011. 6(4): p. 204-12.

2.         Geis, G.L., et al., Simulation to assess the safety of new healthcare teams and new facilities. Simul Healthc, 2011. 6(3): p. 125-33.

3.         Ye, K., et al., Handover in the emergency department: deficiencies and adverse effects. Emergency medicine Australasia : EMA, 2007. 19(5): p. 433-41.

4.         Benjamin, A., Audit: how to do it in practice. BMJ, 2008. 336(7655): p. 1241-5.

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Can we help reduce tribalism with simulation?

I have worked in hospitals all over the world and there is one constant, all of the departments within the hospital don’t like the Emergency Department (ED). There are many reasons for this but one might be  that ED wants to get rid of the patients to reduce their workload and the wards don’t want the patients as it increases their workload. So how can we improve relations. I see the answer in reducing the workloads for both parties by improving communication and processes. An example of this might be a structured handover before the patient arrives on the ward so that the staff have time to prepare. Maybe a checklist could be  completed before leaving the ED to ensure that the patient is correctly packaged and is safe to be managed outside of the ED. It might help in small ways to bring in new processes like this in isolation but wouldn’t it be better the review the transfer of patients within deportments as one process and improve many aspects at one go?

Inspired by Dr Brazil’s work at the Royal Brisbane and Womens Hospital  on the transfer of patient to the Cardiac Catheterization  laboratory I decided to create a scenario of  the  transfer of a patient from Queensland Ambulance Service (QAS) to ED then on to Intensive Care (ICU).

The Team that made it possible:

  • Emergency Educator
  • ICU Educator
  • Medical/Surgical Educator
  • Emergency Consultant
  • Laerdal Rep
  • SimMan 3G

For the simulation to work needed  access to the staff and facilities of the Emergency Department and to the ICU. This was made possible with the excellent working realtionship that I have with their educators. In their respective areas they were able to supply all of the equipment and staff that were needed, and during the debrief they were instrumental in highlighting critical incidents from the scenario. Laerdal Medical kindly provided a SimMan 3G and the Laredal Rep Ronan kindly agreed to drive the manikin for me.  

Patient journey Scenario:

Patient: Des McManus

Summary:

Intensive Care Paramedic calls Emergency Department early warning phone -to advise transporting 24yr old male post Pulseless Electrical Activity (PEA) arrest now has Return of spontaneous circulation (ROSC). ECG shows Atrial Fibrilation (AF). Observations are stable although the patient is hypotensive. Estimated time of arrival 5 mins.

On arrival the 24 yr old male is being manually ventilated with second  bag 1 ltr 0.9% Saline running. Patient has had I round of CPR followed by adrenaline 1mg.

Expected process:

  • Assess patient
  • Appropriate Treatment and intervention
  • appropriate referals
  • Package patient for safe transfer to intensive care
  • Admit to ICU

Background:

Des is a 24 yr old male McDonald’s worker. His family say that he has been complaining of a sore throat headaches and fevers for a few days. He went to his GP who started him on oral antibiotics. Des was at work this morning when he collapsed. He is a non smoker but his father had a heart attack in his 50s.

Props and Gear:

  • Emergency Resuscitation bay and equipment
  • Intensive Care Bed and equipment
  • EDIS/DEM Record
  •  QAS 12 lead ECG–AF
  •  DEM 12 lead ECG–AF
  • Clothing for Des.
  • Emergency Reus team
  • ICU medical and nursing staff
Learning goals:
  • Communication stratergies
  • Transfer protocols
  • Allocation of roles
  • Patient Assessment
  • Clinical Skills

The Scenario was immersive was carried out by the clinicians involved as if it were a real person with excellent buy-in. The debrief lasted for nearly and hour and it became aparent that the team had thoroughly enjoyed the exercise. The debrief focused on the learning goals, particularly process issues for example who hands over the patient to whom and who is responsible for the patient in particluar areas. An unexpected benifit of the scenario was the team building that it produced. It was great to see the nurses and doctors from different speciality talking over the best way to transfer a patient and clearing up areas of confusion. We may discover that greatest benefit of these exercises is the improvemnt in relations between different departments that creates an environment for much greater improvements in patient care.

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How do we get participants for simulation?

SimMan Moulage Twisted ALS

I have been involved in running education for Emergency Registrars for about a year. We run a course called Twisted Advanced Life Support which is a kind of advanced advanced life support. The workshop team consists of an Emergency Consultant, myself and the other simco (lets call him Dave). We developed immersive scenarios based on real presentations. It took me ages to convince the Consultants to let me include nurses in the immersive simulation, before that the docs had been pretending to be nurses with not much success. Eventually I was given the green light to include some of the Emergency Nurses. Because I work in the Emergency Department I already had my foot in the door so I asked the Nurse Unit Manager and the Nurse Educator if they could spare a couple of nurses once a month for the simulations. Everyone was keen and it looked good. The reality was that on the day of the scenarios the ED was always over run with patients and the nurses would either be called back early without having an adequate debrief or they would not be released at all. The feedback from the clinical staff that remained in the department was that there was a significant increase in their workload while their colleagues “mucked about at the skills centre”. I didn’t want these marvellous educational opportunities to cause stress and a negative feeling so I had to come up with an alternative strategy that involved no money and nil impact on the ED. I decided to give the staff the option to come in their own time. I put up some posters and sent out an email to all the nurses who worked in ED. The response was impressive, within a day of the emails going out the workshops were full.  It also occured to me that this might be an opportunity for the nurses to claim the hours as professional development leave so that they would get paid for the hours they attended. There is also talk of the participants organising child care between themselves. I have had to create a waiting list as the courses are now full, I am hoping that this will add weight to my case to increase the use of simulation based education in the Emergency Department.

Whats the next step?

More simulation based education workshops, the challenge will be how to integrate this into the daily workings of  a busy ED.

A teaching programme that feeds from the learning needs identified in the simulations and debriefs.

Create cross department scenarios to eradicate tribalism and improve communication.

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