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.
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).
