INTRO TO CODE BLUE Facilitator Manual

(Last Updated: February 26, 2018)

WELCOME

Welcome to INTRO TO CODE BLUE (ITCB)! Thanks for participating! In a 2-hour workshop, facilitated by you, medical students will learn how to manage select acute care cases as well as have an approach to running a “code blue”! BEFORE ATTENDING ITCB

Prior to bringing your enthusiasm to ITCB, please complete the following:

1. Review the “ITCB Presentation” and “ITCB Presenter Notes” found at http://ucalgary.ca/codeblue/facilitators.

2. Review the 4 simulation OSCEs. The OSCEs can be found at: http://ucalgary.ca/codeblue/osce.

3. Review the ITCB Agenda found at http://ucalgary.ca/codeblue/schedule. DURING ITCB You will be provided with the following materials in your room:

• 1 adult CPR manikin • 1 adult BVM • Post-It Notes • Computer/projector

You will need to bring:

• ITCB Presenter Notes (found at http://ucalgary.ca/codeblue/facilitators): either print this out or use your laptop to view this

• Rhythm strips: print or view electronically (https://ucalgary.ca/codeblue/osce)

• Simulation OSCEs: print or view electronically (https://ucalgary.ca/codeblue/osce)

• Agenda: print or view electronically (https://ucalgary.ca/codeblue/schedule)

• Pens

AFTER ITCB After the session, please complete the following:

1. Encourage learners to fill out their post-ITCB Survey. This will be their second attempt at an online quiz to help them retrieve the learned material one last time.

2. Consider: signing up for a BLS Instructor and ACLS Instructor course ITCB PROGRAM AGENDA Basically, ITCB will have you first conduct a 30-minute lecture, followed by 4 simulation OSCEs, where you will prompt and coach, as needed, the students through the “must-see” checkbox items on the simulation OSCE document (http://ucalgary.ca/codeblue/osce). Time Description 33 minutes ITCB Presentation and questions 16 minutes SIM 1: ACS/VF 8 minutes Debrief 1: ACS/VF 12 minutes SIM 2: Anaphylaxis/Asystole 8 minutes Debrief 2: Anaphylaxis/Asystole 12 minutes SIM 3: Tension PTX/VT 5 minutes Debrief 3: Tension PTX/VT 12 minutes SIM 4: UGIB/PEA 4 minutes Debrief 4: UGIB/PEA 10 minutes Wrap-up and travel to next session

LOCATION The small group rooms are located at the Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB. Please check your email for specific room assignments.

ITCB PRESENTATION

ITCB will kick-off with an overview didactic session, covering key concepts for all 4 acute care cases and how to run a “code blue”. Please preview the presentation and presenter notes here: http://ucalgary.ca/codeblue/facilitators. The presenter notes are just one style of phrasing the content. Feel free to use your own judgment and phraseology. Using the presenter notes as a guide will allow for consistency, accuracy, and quality of workshop delivery. Avoid going into discussions that are beyond the scope of the workshop. There is a 33-minute time limit for the ITCB PowerPoint Presentation, which includes questions. Feel free to accept questions throughout the talk, so that it is kept interactive. Remember to show your enthusiasm! ITCB SIMULATION OSCES

The core of ITCB is the simulation OSCEs, which will help consolidate the knowledge learned and allow for practicing the skills. Each student will rotate through the following roles, where each person will play “team leader” once:

1. Team leader | 2. Airway | 3, Compressor | 4. Meds/Defib

Persons #3 and #4 will swap roles every rhythm check (every 2 minutes) in order to maintain CPR quality. You, the facilitator, will play the role of the “Scribe”. You will keep track of time and tell when and what treatments have been offered thus far. In the case where you have >4 learners (instead of the usual 4), additional learners can act as recorder, co-leader, or co-airway. After you are finished presenting the slides, you will then let the students know that they will now take turns as team leader, going through the 4 simulation OSCEs on the same topics as discussed during the slides, to help consolidate the material and put it into practice. Let them know that these simulation OSCEs are not for marks and have no impact on passing their “Intro To Clinical Practice” course. The whole purpose of this workshop is to learn and practice skills in a safe environment.

When you are ready, open up the simulation OSCEs by going to this link (or use your own printout): http://ucalgary.ca/codeblue/osce. Go through the cases in order, as per the ITCB agenda. You may wish to share with the students that this is like a game, where they are trying to get as many “points” as they can without the need for prompts. The goal is that by the fourth simulation OSCE, they will need zero-to-minimal prompting to collect as many “points” as they can. Each checkbox on the simulation OSCE form is a “must-see” item and acts as a “point”. As you go through each simulation OSCE with your students, you should be coaching them and prompting them along the way, if they are not meeting the “must-see” checkboxes on the OSCE checklists on their own. You want to make sure they are hitting all these “must-sees”. However, if you gave the students a prompt or a hint, you should not check the checkbox and should leave it unchecked. The omissions (un-checked checkboxes) will then form the basis of your feedback to them afterwards. Only check the checkboxes that the students performed independently, without the need for a prompt. During the debrief, you can also highlight what they did well without prompts. Coaching and prompting is a unique aspect of ITCB, where leaners will get continuous feedback, rather than the typical end-of-scenario feedback in high-fidelity simulations. The purpose of the prompting and coaching is to ensure thorough approaches to the primary and secondary surveys. Refer to the “ITCB Program Agenda” that can be printed online (http://ucalgary.ca/codeblue/schedule). Make sure you stick on time. These times work, as they have been piloted. You’ll notice that SIM #1 has 16 minutes allotted for it, whereas the subsequent SIMs #2-4 have 12 minutes each. This is because you will be coaching the learners more for SIM #1 and helping them develop good habits; there will be more constructive intervention, reminders, and prompting. For Debriefs #1-2, 8 minutes are scheduled, whereas 4-5 minutes are scheduled for Debriefs # 3-4. This again allows for more feedback and reflection during the early stages.

By the 4th simulation OSCE, the learners should feel a lot more comfortable with doing primary and secondary surveys, as well as running a “code blue” with effective team dynamics. These simulation OSCEs are not “tests”, so please interject, offer teaching points, and coach learners during the simulations; do not wait until the end of each simulation. During the simulations, let CPR and rhythm-check cycles be performed in real-time. This means that you notify the group when 2 minutes have passed since the last rhythm/pulse check. At that time, they will swap compressors, resume CPR, and decide to shock or not. Equipment

§ Manikins Encourage Learners to perform quality chest compressions on the manikin, as this is a great opportunity to refresh their CPR skills. Remember, 30 compressions to 2 breaths! 100bpm-120bpm! Press deep (i.e. 5-6cm), and allow for maximum recoil! Switch compressors every 2 minutes! These are things you want to remind them during the simulations.

§ BVM Remember to avoid hyperventilation. Press the bag just enough for the chest to rise (e.g. 1/3 may do for a 1600mL bag, which gives about 500mL = tidal volume). Give just enough breath for the chest to rise, over 1 second! Remind Learners of these pointers during the simulations to ensure quality ventilations.

§ Post-It notes We will be using a low-tech, innovative way to administer treatments and medications! If the team leader tells another learner to give epinephrine, the learner will acknowledge the team leader, confirm the dose, and then “prepare it” by writing “IV 1mg epinephrine 1:10,000” on the Post-It Note. Then, to “administer it”, the learner will simply stick it on the manikin, and it’s in its system! To start IVs or to offer oxygen, they can stick “oxygen” on the face or “IV” on the arm in the location they want it.

By using Post-It Notes, this will be an innovative, fun way of learning, using both visual and kinesthetic modalities. By writing it down and sticking it on the manikin, learners commit to the order. They will also have a visual representation of what has been done so far. Feel free to let them be creative. For example, if they are nice and want to offer a “blanket”, then they can write it down and post it! Here are some ideas of Post-It Notes that may be useful for the simulation cases: “oxygen”, “IV”, “monitor”, “AED pads”, “defib pads”, sat probe”, “ASA 160 mg PO”, “200J shock”, “1mg of 1:10,000 epinephrine IV”, “0.3mg of 1:1000 epinephrine IM”, “14G needle”, “normal saline”, “blood transfusion”.

§ Rhythm Strips

You can either use print-outs, computer pictures, or a simulation monitor (e.g. via tablet) to show the rhythms of VF, asystole, VT, and PEA.

§ Laptop

Should you decide to go paperless, the laptop will be useful for viewing your presenter notes, simulation OSCEs, and agenda. The laptop can also be used to show rhythm strips. Most people find printing out a paper copy of the simulation OSCEs useful, as you can manually tick the checkboxes and write down notes to help you during debriefs.

ITCB DEBRIEF SESSIONS Debriefing is educationally important to help understand the material, reflect on the case, and think of ways to improve. Its purpose is to ensure everyone fills in the knowledge and skill gaps identified and consolidate learned material.

The debrief sessions will follow this order:

1. Team leader self-reflection § Ask the team leader how he/she felt (emotional), what was done well

(cognitive), and what can be improved (cognitive) 2. Peer reflection and feedback

§ Ask the team members to add any thoughts, comments, or feedback 3. Facilitator feedback

§ Add comments/feedback that have not yet been covered § Review the simulation OSCE checklist with the group, emphasizing

what they did well and pointing out omissions 4. Discussion

§ Based on what they missed, ask them for solutions as to how they can improve for the subsequent SIMs; then, offer your suggestions

§ Discuss any questions they have regarding the SIM 5. Summary and take-home points

§ Give a summary of what was discussed during the debrief session § Re-emphasize that early CPR and defib saves lives § Give them take-home points and goals for the next SIM

ONE FINAL NOTE ON BUY-IN FOR LOW-FIDELITY SIMULATION One potential challenge you may encounter are some Learners who have difficulty with buy-in for low-fidelity simulation. Re-emphasize for them that the educational design is purposeful. We are stripping away distractions so that knowledge, process, and skills can be practiced deliberately and reinforced through repetition. In end-of-course evaluations, students have actually rated ITCB the highest out of all the sessions in the Intro to Clinical Practice course—even higher than high-fidelity medical simulations, showing that simulations do not have to be high-tech for it to be satisfying and effective for learning. CONTACT Thanks again for participating in ITCB. If you have any further questions, please email avseto@gmail.com (Anthony Seto).