Nursing and Medical Students in interdisciplinary simulations – a good paper

One of the benefits of ISS I appreciate in general practice is getting GP’s and registrars working with the practice nurse, reception staff in an impromptu multi-disciplinary team when we practice our simulations.  This is quite the difference from often working away in our own areas of the practice, interacting only on single tasks.

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This study from Sweden was conducted with simulation laboratory sessions involving both nursing and medical students concurrently.  Scenarios were common ward problems – confusion, breathing problems and vasovagals with the two groups having to work together.  Their debrief flow was vent / what went well / what did not go well / what to change, so a sort of Pendelton’s sandwich however with that vent at the front to get all the jumbled thoughts and feelings out first.  I plan to try this next time with explicitly asking learners to ‘vent” at the start of the debrief and then use a more structured debrief (I tend to use diamond).

OD in the car park!

Last month I attended a real OD in the carpark at our GP clinic. The unresponsive man’s friends notified our reception that he had dropped and I attended, gave some basic airway support, IM nalaxone and then handed over to Victoria Ambulance. I attended that with my Conover-style everyday pack but other doctors were talking about what to do for another OD or multiple casualties, could the emergency trolley get there, how many people would we need –  so I offered to organise an in situ simulation to explore these questions.

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Simple Laedal Little Annie with opportunity store clothes sewn around towel leg/arms. Bluetooth speaker inside with stertorous breathing MP3

Props were syringes with some flash back blood in the hub, pharmacy bags and drug baggies.

The staff were all given warning – unexpected sim I do not feel would really work in the GP setting. I generally run these in the registrar teaching time so I know they are free and the supervisor teaching them.  I then also block out the practice nurse for that first 30min of the day and notify the reception staff. I put up signs at reception and for this one in the car park around it “Medical Emergency Training” so no one is alarmed.  As other people report about in situ simulation, patients are interested and respectful of you demonstrating skills upkeep in the usual clinical space.

Before hand, I provide a preamble to the staff about the focus of the scenario and some background. Opiate Overdose in the Practice. Then I write or adapt my running sheet as a reminder about manipulating the blue tooth speaker, monitor vital signs or other changes.

We ran the team through – two registrars, one GP supervisor, the practice nurse and myself as the simulation educator.  A quick clean up and then debrief in the tea room  saw us use the first 30minutes of the day very fruitfully.

 

SimMon wifi monitor

As per a prior post, a lot of the time, there is no need for a “real” simulated monitor for in situ sim, for the simple reason most of us don’t use them in day to day practice.  However some centres do have them in their procedure bay and so when providing in situ sim at one such place, I did need to step up to a master/slave wifi monitor.

Tim Leeuwenberg has a great review about various options here.

I did trial the SimMonitor initially which is low cost at $AUD20 and connected easily between slave (display) and master(sim educator) iPads.  However I felt that the controls were fiddly, I could not work out how to turn of options that we don’t use in GP (ETCO2) and had to trial black tape on the slave iPad screen to only display pulse, SpO2 and BP.

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SimMon running on a small iPad, unable to turn off ECG trace, ETCO2 trace. (Maybe just me, but SimMonitor would not rotate with the screen – only worked in landscape).  There is black tape over parts of the screen to hide displayed items not needed – temp/BGL/GCS/tests

 

I then purchased the SimMon app at $AUD35 and have found this easier to configure to look like a simple GP  SpO2/BP/HR monitor. It is just as easy to connect between the two iPads and has similar functionality in terms of SpO2 sounds with some added options – poor SpO2 probe connection.

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SimMon running on small iPad, taped to real monitor

A iPad tip: You only need to purchase the app once on one iPad or iPhone and as long as they are registered to the same user, you can download to both iPads for the one cost.  If you are using iPads registered to different users, you can do the same if they are linked as family sharing. SimMon worked for me on a very old iPad2, iPad mini 2 and iPhone 4 and 5.

Simulcast Ep 5 – in situ sim

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This is another stimulating episode from Jessie Spurr(@Inject_Orange) and Prof Victoria Brazil(@SocraticEM) with an obvious application to general practice simulation. They invite Andrew Petrosoniak as a guest who was one of the authors with a recent paper in the Emergency Medicine Australasia focused on in situ simulation for emergency medicine.

One point that I took away were the make sure there are learning points and involvement for the whole team – that in a poorly designed or managed simulation nursing or other staff can  feel like a support cast for the doctors and so disengage. Andrew has obviously been able to involve all-comers as he relates a story of the hospital porter bringing insights during debriefs for their red blanket massive transfusion sims.

Quick Start for GP in situ sim

In homage to How-I-Sim, this is guide to why i decided to start doing in situ sim (ISS), how I started and next close goals.

I had been working in a rural GP setting with lots of oncall, generally not too sick but the occasional poorly patient.  This was still solo GP work however, oncall with one or two nurses. Since leaving internship I had not been exposed to any simulation work and although had been away for weekend courses (ATLS/APLA/ELS), the nurses don’t attend and equipment and work-flow are different when you return to your shop.

Now working in a larger group practice I wanted to improve our team approach to emergencies in the practice, rare but significant for patient, practice and provider.

I enrolled in the Australian Government sponsored NHET-Sim program and completed part one and two of their online course. I drank deeply from the FOAMed out there on the use of Sim – tweets, websites and podcasts.

I purchased a Laerdal Little-Annie and a AED trainer (second hand – no budgets for GP sim!) and drafted my first scenarios.

I presented at the practice meeting that had undertaken some training and wanted to improve the practices’ ability to respond in a crisis with a focus also on registrar training and mandatory CPR training for reception staff.

I wanted involvement of all, the GP’s, practice nurse and reception staff as the difference I wanted to create was the team response to a crisis – common in anaesthetic, pre-hospital or emergency medicine, rarer in general practice.

Timing and duration were two factors important to the other GP’s, there is not budgeted or remunerated training time so time not consulting is money lost.  I suggested 30minute sessions in total – a typed preamble emailed the weeks before, a five minute prebrief, ten minute simulation and fifteen minute debrief.  This is the example of a preamble I emailed particpants for pre-reading on quality CPR.

Simulations were timetabled in the first 30minutes of the working day for minimum patient and staff disruption, on a day I was not working so I could come in, set up and then tidy up in my room while the practice went on with the day. I do not see there is a role for unannounced or guerilla sim in private general practice. Likewise I believe the task needs to be very clear and with my short time frame, one or two tasks only – quality CPR, use the AED, finish or recognise anaphalxysis, give appropriate dose of adrenaline, finish.

It took me six months to get from starting the online training to running my first simulation for the practice however they have been popular, we have identified discrete tasks and pathways that need improvement and I have enjoyed stretching my practice.

Prevent the negative

I ran a short collapse in the practice sim this am before consulting, an arrest requiring CPR then debfirillation. All went well but the hardest component is stopping participants being so negative in their self assessment during debrief!

I have been using the Diamond debrief as being an arrant beginner I find some of the scripts useful.

I really need to focus on letting the facts of the simulation be discussed and reluctantly interrupting the more negative self reflection. Lots to improve for me!

Why in situ sim for general practice?

There is expanding interest in simulation in health care to create a safe space to train individuals and increasingly to build health care team skills. While the published evidence for improved patient outcomes is hard to come by, there are reviews and surveys that suggest simulation does improve confidence and that there are credible patient safety reasons to practice health care tasks in simulation.

General practice for the main part is a single doctor and patient en devour. Certainly there can be practice nurse assistance or calling in a colleague for a second opinion however this is quite different to the hospital ward, emergency department or operating theatre where a team of health care providers orbit around the patient, each adding their portion of care.

Where general practice does become a team is with the management of a crisis in the practice.  With evidence for the patient safety role of Crisis Resource Management (CRM) and the so called soft skills of health care, I was interested in how this could be brought into the general practice rooms.

From the above Emergency Medicine Australasia journal article the stated key elements are important to all areas of health care management in a crisis and not just the hospital:

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Carne, B, Kennedy M Review Article: Crisis Resource Management in emergency medicine EMA (2102)24,7-13

 

These core CRM skills are not natural to general practitioners however, given that we practice largely alone and do not work as a team around one patient.  In a crisis however we are drawn together and working better together must improve patient care for resuscitation and hand over to the ambulance services.

My goal then is create a path for our clinic to develop appropriate CRM skills and for simulation to be a way for us to get there.