Concepts of Emergency/Trauma Nursing and Emergency/Disaster PreparednessSimulation Scenario

Utilizing the QSEN Knowledge, Skills and Attitudes for Pre-Licensure Nurses

Level of Scenario:Beginning _____ Intermediate _____ Complex __X__

Estimated time to complete:6 to 8 hours

Simulation Learning Objectives:At the completion of this simulation, the student will:1) Recognize the patient or designee as the source of control and full partner in providing

compassionate and coordinated care based on respect for patient’s preferences, values and needs.

a. Be able to teach the importance of blood glucose monitoring to the patient with diabetes.

b. Knowledge Integrate understanding of multiple dimensions of patient centered care

- Coordination and integration of care- Information, communication, and education - Physical comfort and emotional support- Involvement of family and friends- Transition and continuity

Demonstrate comprehension understanding of the concepts of pain and suffering, including physiologic models of pain and comfort

Describe the limits and boundaries of therapeutic patient-centered care Discuss principles of effective communication Examine nursing roles in assuring coordination, integration, and continuity

of carec. Skills

Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

Communicate patient values, preferences and expressed needs to other members of health care team

Provide patient-centered care with sensitivity and respect for the diversity of the human experience

Assess presence and extent of pain and suffering Asses levels of physical and emotional comfort Elicit expectations of patient and family for relief of pain, discomfort, or

suffering Initiate effective treatments to relieve pain and suffering in light of patient

values, preferences and expressed needs

Remove barriers to presence of families and other designated surrogates based on patient preferences

Assess level of patient’s decisional conflict and provide access to resources Engage patients or designated surrogates in active partnerships that

promote health, safety and well-being, and self-care management Facilitate informed patient consent for care Assess own level of communication skill in encounters with patients and

families Participate in building consensus or resolving conflict in the context of

patient care Communicate care provided and needed at each transition in care

d. Attitudes Values seeing health care situations “through patients’ eyes” Value the patient’s expertise with own health and symptoms Appreciate the role of the nurse in relief of all types and sources of pain or

suffering Recognize that patient expectations influence outcomes in management of

pain or suffering Value active partnership with patients or designated surrogates in

planning, implementation, and evaluation of care Respect patient preferences for degree of active engagement in care

process Appreciate shared decision-making with empowered patients and families,

even when conflicts occur Value continuous improvements of own communication and conflict

resolution skills2) Function effectively within nursing and inter-professional teams, fostering open

communication, mutual respect, and shared decision-making to achieve quality patient care.

a. Provide SBAR report to the OR nurse. b. Successfully triage victims of a mass casualty event as evidenced by correct triage

tag designations. c. Apply, administer and perform all necessary nursing interventions to a patient with

traumatic injuries.d. Knowledge

Describe own strengths, limitations, and values in functioning as a member of a team

Describe scopes of practice and roles of health care team members Describe strategies for identifying and managing overlaps in team member

roles and accountabilities Recognize contributions of other individuals and groups in helping

patient/family achieve health goals Describe impact of own communication style on others Discuss effective strategies for communicating and resolving conflict

Describe examples of the impact of team functioning on safety and quality of care

Examine strategies for improving systems to support team functioninge. Skills

Demonstrate awareness of own strengths and limitations as a team member

Initiate plan for self-development as a team member Function competently within own scope of practice as a member of the

health care team Assume role of team member or leader based on the situation Initiate requests for help when appropriate to situation Clarify roles and accountabilities under conditions of potential overlap in

team member functioning Integrate the contributions of others who play a role in helping

patient/family achieve health goals Communicate with team members, adapting own style of communicating

to needs of the team and situation Solicit input from other team members to improve individual, as well as

team, performance Follow communication practices that minimize risks associated with

handoffs among providers and across transitions in care Assert own position/perspective in discussions about patient care Participate in designing systems that support effective teamwork

f. Attitudes Acknowledge own potential to contribute to effective team functioning Appreciate importance of intra- and inter-professional collaboration Value the perspectives and expertise of all health team members Respect the centrality of the patient/family as core members of any health

care team Respect the unique attributes that members bring to a team, including

variations in professional orientations and accountabilities Value teamwork and the relationships upon which it is based Appreciate the risks associated with handoffs among providers and across

transitions in care 3) Integrate best current evidence with clinical expertise and patient/family preferences and

values for delivery of optimal health care. a. Perform a rapid trauma assessment on patients with traumatic injuries. b. Knowledge

Describe reliable sources for locating evidence reports and clinical practice guidelines

Explain the role of evidence in determining best clinical practice Describe how the strength and relevance of available evidence influences

the choice of interventions in provision of patient-centered carec. Skills

Locate evidence reports related to clinical practice topics and guidelinesd. Attitudes

Value the concept of EBP as integral to determining best clinical practice Appreciate the importance of regularly reading relevant professional

journals Value the need for continuous improvement in clinical practice based on

new knowledge4) Use data to monitor the outcomes of care processes and use improvement methods to

design and test changes to continuously improve the quality and safety of health care systems.

a. Be able to use lab data and clinical manifestations to determine the effectiveness of treatment.

b. Knowledge Describe strategies for learning about the outcomes of care in the setting in

which one is engaged in clinical practice Recognize that nursing and other health professions students are parts of

systems of care and care processes that affect outcomes for patients and families

c. Skills Use measures to evaluate the effect of change

d. Attitudes Value own and others’ contributions to outcomes of care in local care

settings Appreciate the value of what individuals and teams can do to improve care

5) Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

a. Knowledge Examine human factors and other basic safety design principles as well as

commonly used unsafe practices (such as, work-arounds and dangerous abbreviations)

Describe the benefits and limitations of selected safety-enhancing technologies (such as, barcodes, Computer Provider Order Entry, medication pumps, and automatic alerts/alarms)

Discuss effective strategies to reduce reliance on memory Delineate general categories of errors and hazards in care Discuss potential and actual impact of national patient safety resources,

initiatives and regulationsb. Skills

Demonstrate effective use of technology and standardized practices that support safety and quality

Demonstrate effective use of strategies to reduce risk of harm to self or others

Use appropriate strategies to reduce reliance on memory (such as, forcing functions, checklists)

c. Attitudes Value the contributions of standardization/reliability to safety Appreciate the cognitive and physical limits of human performance Value own role in preventing errors

6) Uses information and technology to communicate, manage knowledge, mitigate error, and support decision making.

a. Knowledge Explain why information and technology skills are essential for safe patient

care Describe examples of how technology and information management are

related to the quality and safety of patient careb. Skills

Apply technology and information management tools to support safe processes of care

Document and plan patient care in an electronic health record Employ communication technologies to coordinate care for patients Respond appropriately to clinical decision-making supports and alerts Use high quality electronic sources of healthcare information

c. Attitudes Appreciate the necessity for all health professionals to seek lifelong,

continuous learning of information technology skills Protect confidentiality of protected health information in electronic health

records

Room Set-up: Adult patient in one hospital bed. Pediatric patient in the other hospital bed. Have a medication room/cart and a computer for charting available. Scatter 15 stuffed animals around the room with one patient scenario and triage tag attached to each stuffed animal. Two of the stuffed animals will “turn into” our patients in the Emergency Department: Patient 9 and Patient 11.

Brief overview of Scenario:A school bus was on its way to a farm for a class trip when the driver lost control, drove

off the highway onto a downward-sloped grass median, causing the bus to turn on its side. The bus contained 1 bus driver, 2 teachers, 2 parents, and 10 preschoolers. Several witnesses called 911 and reported the accident. The fire department and EMS are dispatched to the scene.

A car containing 4 nurses carpooling to a nursing convention came upon the accident about 30 seconds after the fire department arrived. The nurses decided to pull over and offer assistance until EMS arrived. The nurses triage the patients as the fire fighters extricate them from the bus.

Cody is a 4-year-old white male brought in by EMTs (Basic Life Support) via ambulance with a yellow triage tag after being involved in the school bus accident. When the school bus tipped over Cody was thrown from his seat and fell onto the corner of a seat on the opposite

side of the bus, causing blunt trauma to the abdomen. Cody is diagnosed with active internal bleeding in the abdomen and needs to go to the operating room as soon as possible.

Eve is a 61-year-old black female brought in by EMTs (Basic Life Support) via ambulance with a yellow triage tag after being involved in the school bus accident. Eve was a restrained driver, had no apparent injuries, but was believed to be hypoglycemic. Eve is diagnosed with an altered mental status related to hypoglycemia. Once stabilized, she is discharged to home.

Educator will assign 2-4 students to triage the 15 patients. Have the students place a paperclip over the color on the triage tag for each patient. Time the students. Once the students have completed triage, collect the stuffed animals with the patient scenarios and triage tags attached. Discuss each patient scenario with the class and decide if each patient was triaged appropriately.

Transition the clinical group to the Emergency Department. The student nurses will assume the care of Patient 9 and Patient 11.

Date of creation: 02/19/2012Review/revisions: 05/04/2012, 10/05/2012, __________, __________, __________

Brief Description of Patient 9:

Name: Cody GullGender: maleAge: 4Weight: 40 poundsHeight: 37 inchesReligion: noneMajor Support: mother and fatherAllergies: noneMedications: noneImmunizations: ChildhoodPMH: none

Last oral intake: 1 egg and 2 slices of bacon at 7am

History of Presenting Illness: Patient involved in a school bus accident. Bruising over abdomen. Complains of belly pain.

Social History: none

Primary Diagnosis: abdominal bleeding related to blunt trauma

Psychomotor skills required prior to simulation: o Foley catheter insertiono IV set upo Medication administrationo NG tube insertiono Blood specimen collectiono Computer documentation

Cognitive skills required prior to simulation: (i.e. independent reading, video review, computer simulations, lecture):o IV fluid calculationso Lecture/lab on concepts of

Emergency/Trauma Nursing and Emergency/Disaster Preparedness

o Required readings per course outline

Concepts needed for review:o Patient-centered careo Teamwork and collaborationo Evidence-based practiceo Quality Improvemento Safety

Surgeries/Procedures: exploratory abdominal surgery and repair of bleeding site

Setting/Environment: emergency department

Simulator Manikin/s Needed: pediatric male

Props: o Gloveso Patient identification braceleto Pediatric non-rebreather masko ECG leads and wireso Cardiac monitoro Intravenous cathetero IV start kito IV tubing with primary line isontonic

crystalloid running o Urinary cathetero NG tubeo Suction canistero Blood pressure cuffo Pulse-oximetero Blood tubeso Blood transfusion o Cervical collaro Computero Medication cart/room

Assignment of Roles:S = studentE = educator

_S_ Primary Nurse_S_ Secondary Nurse_S_ Family Member #1_S_ Family Member #2_S_ Observer_E_ Physician/Advanced Practice Nurse_S_ Imaging_S_ Unlicensed Assistive Personnel

Identify educator roles needed:

o Informaticso Medical asepsiso Fluid resuscitation

Medications and fluids:o IV fluids: 0.9% NSo IVPB: Zosyn (tazobactam) 12.5mg/kg in

50mL 0.9% NSo IV Push: Morphine

Diagnostics available:o Labso X-rayso CT Scano MRIo ECG

Student information needed prior to scenario:o Has been oriented to simulatoro Understands guidelines/expectations for

scenarioo Has accomplished all pre-simulation

requirementso All participants understand their assigned

roleso Has been given time frame expectations

Report students will receive prior to starting the simulation (report from EMS responders):

Cody is a 4 y/o white male brought in by EMTs (Basic Life Support) via ambulance with a yellow triage tag after being involved in a school bus accident. When the school bus tipped over Cody was thrown from his seat, and fell onto the corner of a seat on the opposite side of the bus. A cervical collar was placed as a precaution and he was placed on a back board. Cody was on scene for approximately 20 minutes waiting for an available ambulance. He is complaining of abdominal pain and bruising to the left

Educator will give patient responses to any/all actions performed by students.

Important information related to roles:At least one observer should be noting what is being done correctly, wrong, and what is questionable.

Critical Lab Values: Hgb 11, Hct 45%, RBC 4.0

Medication Calculations: Fluid resuscitation using Pediatric Advanced Life Support (2010) recommendations 20mLs/Kg isontonic crystalloid for treatment of hemorrhagic shock in the pediatric patient.

Zosyn (tazobactam) 12.5mg/kg in 50mL 0.9% NS

Morphine 0.05 mg/kg (up to 15 mg)

Blood pressure calculation in pediatric patients SBP 70 + (2 x age in years)

abdomen and left retroperitoneal area has been noted. No other injuries have been noted. Oxygen is being administered via non-rebreather mask. Parents are on their way to the hospital, but have not yet arrived.

VS on scene: BP 78/46, HR 120, RR 32.

VS in ambulance: BP 76/46, HR 126, RR 28

Scenario Progression Outline: Patient 9Timing Programming Data Expected

InterventionsTeaching Points for

DebriefingInitial Stage:VS: BP 70/40, HR 130, RR 28, temp 98.1

Resp: Maintaining own airway, lungs clear, cervical collar in place

CV: Sinus tachycardia, weak pulses all 4 extremities

Neuro: AAO, PERRLA, able to move all extremities, GCS 15

Program VS

Have manikin moan with pain

Lung sounds clear

Muffled bowel sounds

Wash hands

Don personal protective equipment

Confirm patient identity

Collaborate with healthcare team

Continue O2 100% NRB

Place patient on ECG monitor

Initial care of the trauma patient in the emergency department

ABCDEFGHI of rapid trauma assessment

SAMPLE history

Facilitating family presence

Fluid resuscitation

Labs anticipated

GI/GU: muffled bowel sounds

Skin: bruising to the left abdomen and left retroperitoneal area

Pain: Points to crying face on Faces Scale

Obtain vital signs

IV access x 2, large bore

Obtain blood specimens: CBC, BMP, T&C, blood glucose

Determine IV fluid dose (364 mLs 0.9% NS)

GCS should be done

Remove clothing, cover with warm blanket

Insertion of foley catheter

Check urine for blood

Consider insertion of NG tube

Bring family in for SAMPLE history, inform family of patient status, allow family to remain with patient

Medication for pain and sedation for diagnostic testing

Remove from backboard

Send for CT head, neck, chest, abdomen, and pelvis

Physical comfort and emotional support

Communication with the team

Minimizing harm to patient and providers

Chart assessment and interventions

Stage 1: Worsening ConditionVS: BP 65/palp, HR 160, RR 20

Resp: snoring respirations at 20 BPM

CV: Sinus tachycardia, weak central pulses, unable to palpate peripheral pulses

Neuro: losing consciousness, GCS 10

Skin: cold, clammy, diaphoretic

Program new vital signs

Give results of procedures:o Hgb 11, Hct 45%,

RBC 4.0, all other labs normal

o X-ray cervical spine negative

o CT abdomen, positive bleeding from spleen

Give assessment information in response to student questions of that system.

Adjust head position to maintain airway

Insert advanced airway (nasal) and use bag, valve, mask ventilation

Obtain consent for emergency blood transfusion

Begin emergency blood transfusion

Begin antibiotics

Obtain consent for surgery

Utilize pre-surgical checklist

Give SBAR report to OR nurse

Chart assessment and interventions

Patient prep for surgery

Communication with the team

Minimizing harm to patient and providers

Informed consent for care

Core Measures: Surgical Care Improvement Project

Brief Description of Patient 11:

Name: Eve BreslinGender: femaleAge: 61Weight: 185 poundsHeight: 63 inchesReligion: BaptistMajor Support: HusbandAllergies: noneMedications: none (prefers not to take)Immunizations: childhood

Psychomotor skills required prior to simulation:o IV set upo Medication administrationo Blood specimen collectiono Use of glucometero Computer documentation

Cognitive skills required prior to simulation: (i.e. independent reading, video review, computer simulations, lecture)

PMH: Type 2 diabetes, hypertension

Last oral intake: half bottle of water just before accident

History of Presenting Illness: Patient was the driver of a school bus when she drove off the highway onto a downward-sloped grass median, causing the bus to turn on its side. She was wearing her seatbelt.

Social History: smokes cigarettes, 1 pack per day

Primary Diagnosis: altered mental status related to hypoglycemia

Surgeries/Procedures: none

Setting/Environment: emergency department

Simulator Manikin/s Needed: Adult female

Props:o Gloveso Patient identification braceleto Adult non-rebreather masko ECG leads and wireso Cardiac monitoro Intravenous cathetero IV start kito Blood pressure cuffo Pulse-oximetero Blood tubeso Cervical collaro Computer

Assignment of Roles:S = studentE = educator

_S_ Primary Nurse_S_ Secondary Nurse

o Lecture/lab on concepts of Emergency/Trauma Nursing and Emergency/Disaster Preparedness

o Required readings per course outline

Concepts needed for review:o Patient-centered careo Teamwork and collaborationo Evidence-based practiceo Quality Improvemento Safetyo Informatics

Medications and fluids:o Dextrose 50% 25g/50mL prefilled syringe

IV push

Diagnostics available:o Labso X-rayso CT Scano ECG

Student information needed prior to scenario:o Has been oriented to simulatoro Understands guidelines/expectations for

scenarioo Has accomplished all pre-simulation

requirementso All participants understand their assigned

roleso Has been given time frame expectations

Report students will receive prior to starting the simulation (report from EMS responders):

Eve is a 61 y/o black female brought in by EMTs (Basic Life Support) via ambulance with a yellow triage tag after being involved in a school bus accident. Eve was wearing her seatbelt and firefighters had to cut the restraint to remove her from her driver’s seat.

_S_ Family Member #1_S_ Observer_E_ Physician/Advanced Practice Nurse_S_ Imaging_S_ Unlicensed Assistive Personnel

Identify educator roles needed:Educator will give patient responses to any/all actions performed by students.

Important information related to roles:At least one observer should be noting what is being done correctly, wrong, and what is questionable.

Critical Lab Values: blood glucose 31

A cervical collar was placed as a precaution and she was placed on a back board. Eve told the EMTS that she was feeling shaky before she lost control of the bus. She believed her sugar was low due to skipping breakfast this morning. She was cold, clammy and diaphoretic on scene and waited approximately 25 minutes for an available ambulance. During the wait, Eve developed an altered mental status. EMTs attempted to administer oral glucose, but Eve became combative and spit it out.

In route to the hospital, oxygen is being administered via non-rebreather mask. Her husband is on his way to the hospital, but has not yet arrived.

VS on scene: BP 146/78, HR 112, RR 24.

VS in ambulance: BP 140/76, HR 120, RR 22

Scenario Progression Outline: Patient 11Timing Programming Data Expected

InterventionsTeaching Points for

DebriefingInitial Stage:VS: BP 140/78, HR 120, RR 22, temp 97.6

Resp: lungs diminished bilaterally, cervical collar in place

CV: Sinus tachycardia, pulses all 4 extremities

Neuro: responsive to verbal stimuli, pupils 4, equal and reactive, GCS 13

GI/GU: positive bowel sounds

Program VS

Lung sounds diminished

Normal bowel sounds

Give result of blood glucose: 31

Wash hands

Don personal protective equipment

Confirm patient identity

Collaborate with healthcare team

Continue O2 100% NRB

Place patient on ECG monitor

Obtain vital signs

Initial care of the trauma patient in the emergency department

ABCDEFGHI of rapid trauma assessment

SAMPLE history

Facilitating family presence

Labs anticipated

Hypoglycemia treatment

Communication with

Skin: cold, clammy, diaphoretic

IV access

Attempt to feed patient

Obtain blood specimen: CBC, BMP, T&C, blood glucose

Give dextrose

GCS should be done

Remove clothing, cover with warm blanket

Bring family in for SAMPLE history, inform family of patient status, allow family to remain with patient

Remove from backboard

CT scan head, neck

Chart assessment and interventions

the team

Minimizing harm to patients and providers

Stage 2:VS: BP 150/80, HR 106, RR 16

CV: Sinus tachycardia, pulses all 4 extremities

Neuro: AAO, PEERLA, able to move all extremities, GCS 15

GI/GU: positive bowel

Program new vital signs

Give results of procedures:o Repeat blood

glucose 82, all other labs normal

o X-ray cervical spine negative

Give assessment information in

Remove cervical collar

Feed patient protein and carbohydrates

Diabetic education

Chart assessment and interventions

Patient-centered care

Discharge instructions

sounds

Skin: warm and dry

response to student questions of that system.

Debriefing/Guided Reflection Questions for this Simulation

How do you feel you performed triaging at the multiple casualty event?

What could be improved with your triaging?

Did you obtain consent to treat the pediatric patient? How?

How do you feel you performed your rapid trauma assessment?

What could be improved with your rapid trauma assessment?

Did you remember to implement all nursing interventions for your patients in the emergency department?

Did you assess for pain and comfort?

How did you collaborate with other healthcare providers to assure that your patients were comfortable?

How did you coordinate care in the emergency department to provide patient-centered care?

How did you feel about having the family stay in the room with your patient?

Do you feel that you communicated your needs and the needs of the patient clearly to the healthcare team?

Why was it important for you to conduct a pre-surgical checklist and provide an SBAR report to the OR nurse?

Recognizing that the patient is source of control and full partner in care, were you able to educate Eve on the importance of diabetes management?

How will you improve your triage, rapid trauma assessment and nursing intervention skills?

Do you feel ready to participate in a drill or a disaster after this week? Why or why not?

References

Emergency Nurses Association (2007). Disaster management. In Trauma nursing core course provider manual (6th ed.) (pp. 249-272). Des Plaines, IL: Emergency Nurses Association.

Ignatavicius, D. & Workman, M.L. (2010). Concepts of emergency and disaster preparedness. In Medical-surgical nursing: Patient-centered collaborative care (6th ed.) (pp. 159-168). St. Louise, MO: Saunders Elsevier.

Ignatavicius, D. & Workman, M.L. (2010). Concepts of emergency and trauma nursing. In Medical-surgical nursing: Patient-centered collaborative care (6th ed.) (pp. 126-140). St. Louise, MO: Saunders Elsevier.

Quality and Safety Education for Nurses (2012). Competency KSAs pre-licensure. Retrieved from http://www.qsen.org/ksas_prelicensure.php

The Joint Commission (2012). Surgical care improvement project. Retrieved from http://www.jointcommission.org/surgical_care_improvement_project/

Laskowski-Jones, L. (2010). Concepts of emergency and disaster preparedness. In Ignatavicius, D. & Workman, M.L. (Eds.), Medical surgical nursing: Patient-centered collaborative care (pp. 159-168). St. Louis, MO: Saunders Elsevier.

Laskowski-Jones, L. & Toulson, K. (2010). Concepts of emergency and trauma nursing. In Ignatavicius, D. & Workman, M.L. (Eds.), Medical surgical nursing: Patient-centered collaborative care (pp. 126-140). St. Louis, MO: Saunders Elsevier.