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PHS AND AFFILIATES

SCE: OB Blood Administration

Perinatal Clinical Academy

Simulated Clinical Experience and Facilitator Guide

Last Revision: June 13, 2016

Perinatal Clinical Academy_ SCE OB Blood Administration ‐ 2

Leena Singh

Age: 28 Weight: 70 kg

Learner Information You will be providing care for a 28‐year‐old female G1 P1001 who is status post c‐section for postdates. She had a mild postpartum hemorrhage in the OR and her recovery has been going well. She is slightly hypotensive with a BP of 90/50 and her hematocrit is pending. Baby Girl Singh was born at 42 weeks gestation and weighed 4.4kg, the baby is on the glucose protocol, and the last glucose was 55. Facilitator Information In this scenario the learner is expected to perform safety checks, verify orders and complete a full and accurate assessment of the patient. The patient will receive PRBC’s according to protocol and the learner will practice the psychomotor and standards process for blood administration, including; conditions to receive blood, ordering blood, blood component pick up, independent double checking of blood products and blood administration. The patient will begin to decompensate into a respiratory distress from anaphylaxis and will need to be recovered with epinephrine according to standards.


Pre SIM Preparation Required

Patient: Leena Singh Age: 28 Weight: 70 kg

You will be providing care for a 28‐year‐old female G1 P1001 who is status post c‐section for postdates. She

had a mild postpartum hemorrhage in the OR and her recovery has been going well. She is slightly hypotensive

with a BP of 90/50 and her hematocrit is pending. Baby Girl Singh was born at 42 weeks gestation and weighed

4.4kg, the baby is on the glucose protocol, and the last glucose was 55.

• Assesses and maintains safe and complete care of both mother and baby • Performs head to toe physical assessment and focused assessments as indicated • Administers blood products per policy • Prioritizes the nursing management of a patient receiving blood or blood products • Recognizes the signs and symptoms of an adverse reaction to blood component administration • Evaluates the patient’s response to interventions and modifies the nursing care as appropriate for the

patient experiencing an adverse reaction to blood component administration • Administers medications per protocol • Utilizes the Nursing Process • Maintains effective closed loop communication with all members of the health care team • Demonstrates safe and comprehensive medication administration • Provides a culture of safety for all patients • Demonstrates awareness of clinical environment, infection control, aseptic technique, fall prevention,

skin care, behavioral health , and pain management • Demonstrates caring and advocacy for patient and family

Preparation required:

Review the following medications and be prepared to administer: • Epinephrine (for anaphylaxis) • Diphenhydramine • Acetaminophen • Oxygen • Blood: Packed Red Cells

Review the following Evidence Based Practice (EBP) and institution specific policies around:

Blood and Blood Component Administration

Anaphylaxis/Hypersensitivity Treatment

Oxygen Administration

Neonatal Glucose Screening

Neonate and Infant Heel Stick Blood Sampling

Newborn Management

Skin‐To‐Skin

Benefits of Breastfeeding


SIM Set Up Checklist SCE: OB Blood Administration Print patient labels with correct birthdate and MRN, then label patient, labs, orders appropriately.

Standard Room Supplies‐ may differ by facility

Family observer clipboard and SAFETY /QUALITY OBSERVER CHECKLIST

Oxygen regulators x2 with Adult ambu bag hanging and Non rebreather mask on O2 regulator

Suction regulators, canister, suction tubing and yankuar in package sitting on top x2

Adult and Newborn Stethoscopes x4

Bathroom: peri‐care supplies (Pink bucket with Mesh panties, chuks pads x4, large pads x2, small pads x2, peri bottle) and urine hat

Call Bell, thermometer (oral and temporal), flashlight, reflex hammer

Code cart in hallway with first responder box on top

Extra pillows

IV pump

Monitor

Neonatal code cart in hall

Over‐the‐bed table

WOW

For PP/ANTE

Bassinet with bulb suction in bed o Top drawer; neonatal ambu bag, pink basin with bath supplies ( yellow comb, J&J soap,

dry washcloths) diapers and wipes, shirts, blankets

Breast pump and parts

Supplies for OB Blood Administration Sim

Manikin Adult female and infant

BABY: o Bassinet with blue bulb suction, and crib card o Check that baby has: ID Band, Hugs Tag, hat, t‐shirt, diaper,

swaddle blanket. o Baby in patients arms

MOTHER: o Patient in bed o IV infusion capability; IV (18 gauge) in both arms. o IV fluids; LR at 125 ml/hr in left arm, Right IV saline locked o Patient ID band and baby band, BP cuff on, sat monitor, and gown

on patient o Patient paper chart on WOW‐includes: Fall risk sign, blood

component pick up form, verification of informed consent for blood transfusion form

o Postpartum belly with hard fundus at umbilicus o Post C/S Dressing: ABD dressing on lower abdomen with the thick

foamy/stretchy tape. o SCD’s on bilateral lower extremities

Tech Recording equipment ready‐ if available

Manikin specific control software ready to go

Facilitator guide


Medication and Supplies – Place in “med room”

Diphenhydramine 25mg IV

Acetaminophen 650mg PO

Epinephrine for anaphylaxis

Normal Saline

One unit PRBC [with transfusion report and lab sign‐out paperwork and placed in a bio hazard bag]

Runner: Supplies to be placed in control room

Facilitator guide (marked as revision guide)

Handoff/SBAR

Labs Conference Room Flipchart and Markers

Facilitator Guide

Learners Roles and Responsibilities

For demonstration‐ Blood Tubing, PRBC bag and transfusion report, 500cc NS

OPTIONAL: Blood administration step by step ( blank for learner; answer key for facilitator)


PREBRIEF

Introduce yourself

Pull up Standards for the learners

o Use the links to access job aids and pinpoint specific education

o Use EPIC to review documentation

Check in with residents: Ask learners about their experience with blood administration

OPTIONAL: (see appendix) Use the blood administration Step by Step educational aid to explore the blood administration process

EXPLORE THE BLOOD ADMINISTRATION PROCESS

WHAT IS THE DIFFERENCE BETWEEN A TYPE & CROSS AND A TYPE & SCREEN?

DISCUSS RH FACTOR AND IMPORTANCE IN PREGNANT WOMEN

WHEN DO YOU NEED TRANSFUSION CONSENT?

WHO IS RESPONSIBLE FOR OBTAINING WRITTEN CONSENT FOR A BLOOD TRANSFUSION AND WHAT FORM IS USED?

WHAT SUPPLIES DO YOU NEED?

WHAT ASSESSMENTS DO YOU NEED TO COMPLETE?

HOW DO YOU PICK UP THE BLOOD?

HOW DO YOU CHECK THE BLOOD?

IF THE INFORMATION ON THE BLOOD COMPONENT DOES NOT MATCH THE INFORMATION ON THE PATIENT’S CHART EXACTLY, WHAT SHOULD YOU DO?

SHOW PRIMING OF BLOOD TUBING

WHAT TYPE OF PATIENT EDUCATION DO WE GIVE?

HOW DO YOU SET THE PUMP? RATE? VOLUME? TO START BLOOD? THEN TO ADMINISTER?

RECHECKS?

WHERE/WHAT DO YOU DOCUMENT FOR BLOOD ADMINISTRATION?

EXPLORE SUSPECTED TRANSFUSION REACTIONS AND TREATMENT

TYPES OF TRANSFUSION REACTIONS

DISCUSS POLICY AND PROCEDURES: HOW TO ACCESS AND USE WHILE ADMINISTERING BLOOD

REVIEW OBJECTIVES FOR THIS SIM

• Assesses and maintains safe and complete care of both mother and baby • Performs head to toe physical assessment and focused assessments as indicated


• Administers blood products per policy • Prioritizes the nursing management of a patient receiving blood or blood products • Recognizes the signs and symptoms of an adverse reaction to blood component administration • Evaluates the patient’s response to interventions and modifies the nursing care as appropriate for the

patient experiencing an adverse reaction to blood component administration • Administers medications per protocol

REVIEW THE EXPECTATION OF SIMULATION

When in doubt, “treat it as real”

Operate as a TEAM

Think OUT LOUD

Use SBAR for all communication

Educate the patient and family member

Demonstrate caring and compassion

Demonstrate excellent safety practices o Patient identification o Infection prevention “Gel in Gel out” o Skin management o Pain management o Fall prevention o Medication safety and double checks

Care for yourselves o Wear gloves o Protect your body

ASSIGN ROLES FOR SIMULATION

See Appendix for Roles descriptions

Give reminder about EPIC (signed and held orders, if applicable) and send to learners to break. Please let

support staff know you are on break so they can finish preparation for SIM


Overview Chart of SIM Highlights

State 1: Initial Assessment

Mother VS: HR in the 100s, BP in the 90s/50s, RR in the 20s, SpO2 in the mid 90s on room air and a Temp of 98.6°F. Pain: 2/10

Baby VS: HR 140, RR 52, Temp 98.9°F Physical Assessment: Normal Glucose: 58

Learners Facilitator Patient TECH

All entering room should gel hands

1. Introduce self to patient

2. Begin comprehensive maternal assessment; VS, pain level, SpO2 level, CMS

3. Comprehensive newborn assessment; VS, head‐to‐toe, BF/Latch, I&O

4. Ensure saline lock intact & patent

5. Performs pre‐transfusion checks Consent signed

VS taken

Patient education

6. Sends runner for first unit

of PRBC with proper paperwork.

7. Documents information

Cues tech to transition to State 2‐Blood Arrives when blood has arrived in room.

Alert and Oriented

Dizzy, lightheaded

Minimal pain, feel okay, just tired?

Ask if getting blood is going to be ok with breastfeeding.

Why do I need blood, can I just take more iron pills?

Is the blood transfusion safe? Pt is anxious about effect on newborn.

RUNNER: Give SBAR report. State that labs are pending and LIP will want to transfuse if Hct remains “low” PRBCs are available in TSL.


State 2: Blood Arrives Mother VS: HR in the 100s, BP in the 90s/50s, RR in the 20s, SpO2 in the mid 90s on room air and a Temp of 98.6°F. Pain: 2/10

Baby VS: HR 155, RR 50, Temp 98.6°F Physical Assessment: Normal



1. Verifies blood product with another approved HCP

2. Documents on transfusion report

3. Hangs blood using proper tubing

4. Starts blood infusion slowly

5. Documents data

When all steps are complete:

Announces: “10 minutes have passed” – Cue patient c/o anaphylaxis

Cue tech to transition to State 3‐ Mild Anaphylaxis.

Voice of Patient responding calmly to RN’s questions

Somewhat quiet so residents can focus on task.

Pt wants to be napping.

**Bookmark when the blood arrives in the room**

LIP ORDERS:

None


State 3 : Mild Anaphylaxis Mother VS: HR in the 100s, BP in 80s/50s, RR in low 20s and SpO2 in mid 90s on RA,T 98.6F

Progresses to HR‐120s, BP‐ remains low, RR‐20s and SpO2 in high 80s on RA



1. Notes change in VS and performs focused assessment

2. Calls for another nurse and moves baby from mom’s arms to bassinet

3. Stops blood

4. Calls RRT/Code Blue

5. Informs LIP of patient’s condition using SBAR

6. Clarifies epinephrine order as IM route, and reads back order

7. TORB diphenhydramine 25 mg IV and normal saline bolus 500ml

8. Gives epinephrine using correct syringe/needle

9. Initiates NS bolus

10. Applies oxygen

If time in State 3 is more than 2 minutes, progress to State 4‐Severe Anaphylaxis.

If epinephrine given IV cue tech to State 7‐Ventricular Fibrillation

Very anxious

Patient stating she is having trouble breathing, talking and is feeling anxious; SOB, tongue feels funny

“There’s something wrong with me!”

“Why does my toungue feel like it’s swelling?”

“I’m scared.”

If time in State 3 is more than 2 minutes, progress to State 4‐Severe Anaphylaxis.

LIP ORDERS: Epinephrine 0.3 mg (no route given). If questioned about route of administration, healthcare provider replies “IM”. Diphenhydramine 25 mg IV and Start 500 mL normal saline bolus.


State 4: Severe Anaphylaxis VS: HR‐in the 140s, BP70s/40s, RR in low 30s and SpO2 in mid 80s with oxygen, T 98.6F


Continued from State 3…

1. Focused ongoing assessment

2. Initiates Emergency response

3. Gives epinephrine using correct syringe/needle

Cue tech to transition to State 5 ‐Epinephrine given IM when Epinephrine is given

If epinephrine given IV cue tech to State 7‐Ventricular Fibrillation

Wheezing and can’t breathe, not talking much, grunting.

Pt acts panicked

**Bookmark video of epinephrine injection**

LIP ORDERS:

Epinephrine 0.3 mg (no route given). If questioned about route of administration, healthcare provider replies “IM”. Diphenhydramine 25 mg IV and Start 500 mL normal saline bolus.


State 5: Epinephrine given IM Mother VS: HR in the 170s, BP in the 120s/90s, RR in 20s and SpO2 in low 90s with oxygen and Temp 100.5°F



1. Performs focused assessment

2. May perform double check on blood unit and patient ID

Cues tech to transition to State 6‐Recovery when assessment complete.

Slow improvement, deep breathes, scared, but less anxious.

Alert and oriented

LIP ORDERS:


State 6: Recovery Change of Shift Report Mother VS: HR in 100s‐110s, BP in 100s/70s, RR in teens, SpO2 in upper 90s with oxygen at 2l per nasal prongs, T 100.5F

Baby VS: HR 155, RR 50, Temp 98.6°F



1. Titrate oxygen down and Exchange NRB for nasal prongs.

2. Notifies TSL of blood reaction

3. Gives shift handoff report uses SBAR

Simulation Complete! Voice of Patient responding to RN’s questions

Patient asking for clarification of what happened.

LIP ORDERS:


State 7 : Ventricular Fibrillation Patient’s condition deteriorates

VS: HR 0, BP in the 20s/20s, RR‐0 CV: cardiac monitor shows course VF Lungs: Breath sounds absent, patient is cyanotic



1. Recognize and verbalize emergency

Scenario complete after participants recognize the emergency.

>>If epi is given via IV: Once learners recognize change in patient, STOP the scenario ‐IMMEDIATELY DEBRIEF

Do not speak, you are unresponsive!

If you get to this state:

1. Facilitator will stop scenario

Reset the room and prepare to restart at State 3 – Mild Anaphylaxis

Debrief for Adverse Patient Event

Remember to “convey a commitment to respecting learners and understanding their perspective”

1. What happened to the Patient? Why?

2. How did you know? What changes did you see?

3. If that happen on your unit what steps would you do next?

4. What is the correct way to give epinephrine? ( walk them through it, show them the supplies)

5. Reinforce that this is why we do simulation, no one was hurt and we learned what to do!

6. Take a break and breathe

7. Go back to simulation room; restart simulation at State 3 – Mild Anaphylaxis

a. Team may require high level of coaching to ensure a successful outcome

8. After completion of successful scenario‐ continue to debrief the entire experience. After completion of successful scenario‐ continue to debrief the entire experience


DEBRIEF

The goal of the debrief is to provide the opportunity for the residents to share and reflect as a group on areas for improvement and recognize practice behaviors that demonstrate excellence. Remember to:

Remind residents that the debrief is a safe place and the purpose is for them to learn from their experiences

Try to use the video ( if applicable) when it fits

Ask the family member their observations

Use standards as needed for clarity/guidance

Use “what if” questions

Embrace the silence

END with: What one thing are you going to take away from this experience?

The template below is available for groups that struggle to facilitate the debrief on their own… REVIEW OBJECTIVES FOR THIS SIM

• Assesses and maintains safe and complete care of both mother and baby • Performs head to toe physical assessment and focused assessments as indicated • Administers blood products per policy • Prioritizes the nursing management of a patient receiving blood or blood products • Recognizes the signs and symptoms of an adverse reaction to blood component administration • Evaluates the patient’s response to interventions and modifies the nursing care as appropriate for the

patient experiencing an adverse reaction to blood component administration • Administers medications per protocol • Utilizes the Nursing Process

General

What worked, what didn’t work and what will you do differently next time?

What was the experience like for you?

What happened and why?

What did you do and was it effective?

Discuss your interventions (technical and non‐technical). o Were they performed appropriately o Were they performed in a timely manner?

How did you decide on your priorities for care and what would you change?

How did patient safety concerns influence your care? What did you overlook?

In what ways did you personalize your care for this patient and family members (recognition of culture, age, concerns, anxiety)?

Discuss your teamwork. How did you communicate and collaborate?

WHAT ARE YOU GOING TO TAKE AWAY FROM THIS EXPERIENCE?


APPENDIX

References:

Micromedix

AWHONN. (2014). Perinatal nursing. (4th Ed.). Simpson, K.R. and Creehan, P.A. (Eds.). Philadelphia, PA:

Lippincott Williams & Wilkins.

Adapted from: CAE Nurse Residency Program


SAFETY /QUALITY OBSERVER CHECKLIST

As the safety and quality observer, it is your job to watch for the safety and quality of care given to

the patient, as well as ask questions and advocate for the patient. Please make note of the following

safety/quality behaviors, plus any other observations you think could enhance the learning of your

team.

Were they observed? How often? What was done well, what could have been done better?

RN1 RN2 Data

Hand washing

Introduction to patient

Bedside report

Whiteboard

Initial safety check &

ID checks

Assessment of skin, pain,

environment, falls risk, etc.

Appropriate choice of

equipment/supplies

Medication administration &

Medication double checks

(using the 5 rights)

Aseptic technique &

Infection control

Explanation & education to

patient

Sharing of information

Team communication &

delegation

Other notes to share with the team:


Learners Roles and Responsibilities

Role Responsibility

RN 1

Primary nurse assigned to the patient

Coordinates overall care of the patient including triage and focused assessments Demonstrates effective and efficient collaboration and communication with team

members Obtains history/admit information in the EPIC ED Navigator Delegates interventions and tasks appropriate for situation Family and patient support and education Utilizes resources appropriately

(charge nurse, RT, preceptors, providers, code teams)

RN 2

Partners with primary nurse to provide patient care

Actively assists with triage assessments and admit tasks Prioritizes interventions and tasks Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Utilizes resources appropriately

(charge nurse, RT, preceptors, providers, code teams)

RN 3 & Data Collector

Facilitates

communication and participates as

additional support

Performs and manages patient care as directed by primary nurse Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Ongoing data collection and documentation (included but not limited to assessment,

labs, observations) Analyzes data collected for trends and missing information

Family Member

Patient Advocate and Safety Observer

Advocates for patient and self Asks questions and expects services, support, and education Acts as Safety Observer: May prompt team if gaps are noted Examples: Safety

Hand hygiene Patient identifiers Medication administration Environmental awareness

Patient satisfiers Introductions completed by all staff / name and role Pain management Receives information regarding treatment plan

Communication Delegation Closed loop communication Sharing of information

Expected to report back to team observations during debrief


Initial Lab Results

Procedure Pt results Reference Ranger per

Facility

WBC 4.8

RBC 2.48

Hgb 6.9

HCT 20.2

ABO O

RH Positive

Antibody Screen Negative

Product Red Blood Cells

Unit ID W 141609 870524

Interpretation Compatible

Product Status Cross Matched

GB Strep DNA Negative