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Delirium and Dementia – Simulation Scenario 3 – Busy Ward

Scenario OverviewMajor Problem

MedicalUTI Sepsis + DeliriumNew patient admission to wardPatient Discharge pending TTO

NTSTeam work / CommunicationUtilising available resourcesSituational awarenessPrioritise & decision making

Learning Goal

Clinical / MedicalRecognition and management of sepsisDelegation / allocating resources

Narrative Description

It is a busy weekday on the ward. There are 3 issues in play:1. Bob Greycoat, a 78 year old man who is agitated and restless, his

Nurse & OT have been utilising the wander guard system which is alarming constantly. (Actor)

2. Albert Adams, an 80 year old man, has become acutely unwell and delirious. He is PAR scoring 4. (manikin)

3. Victoria ward needs to transfer a patient over ASAP who will require admission by the nursing staff (including STRATIFY falls assessment and a phone call to relatives as per OPU guidelines).

4. The pharmacist is trying to urgently prepare a complex TTO for a patient who is due to be discharged today. The discharge lounge porter has arrived to collect the patient, but the TTO cannot be found.

(See below for narratives of each patient)Staffing Faculty Control Room:

1 x technician1 x patient voice1 x debriefer1 x nurse from acute ward (making tel call)

Faculty Role Players:1 x staff nurse plant1 x Actor (Patient 2)1 x Actor/plant (Porter)1 x Actor/plant(Pharmacist)

Case Briefing

To All CandidatesIt is 11.am, midweek on the general ward. You have been asked to review Albert Adams, an 80 year old male, who has become increasingly confused overnight. He is now PAR scoring 4, and the NA is concerned the patient looks unwell.

Candidates:Staff nurse x 2 (I at a time) Doctor x 2 (on ward round at 1st)

Manikin preparation

Patient not attached to any monitoring but has IV access: 24G (pink) cannulaCatheter insitu, ideally with urometer which is empty

Room set up

As per ward. Locker & bedside chair & table at each bed spaceEmpty made-up bed in second bay with chair beside it.

Simulator operation

Patient 1 (SimMan):Patient initially talking but confused and disorientated (MMTS 3/10). He becomes more agitated as he deteriorates. He improves if given fluids,

Delirium and Dementia – Simulation Scenario 3 –Busy Ward page 1 of 17 Draft V3 - CLC Feb 2014

Abx, O2 and appropriate de-escalation techniques used.Patient 2 (actor):Patient is mildy agitated and restless. He is disorientated. – He sits up and down – setting off the wander guard. He should not get up and be distracting / fall until they have focussed on the sepsis pt.Patient 2 (actor):The porter has arrived to collect a patient but he needs assistance of 1 to transfer to chair/bed. Porter will not leave until he gets help.

Props needed

Patient 1 (SimMan):Foley Catheter, urometer, dark stained urine (drops), iv fluids on Syringe driver or pump – Monitor set up to alarm, phone to ring as a distraction, call bell from another patient Drugs: Abx, paracetamol, IV fluids, PyjamsaPatient 2 (actor):Pyjamas and dressing gown, Notes, Wander guard system



Running order:

Manikin set up for UTI/Sepsis. NA / Nursing staff go in to assess. Junior medical staff go in to assist when / if called. Whilst patient 1 (SimMan) is being assessed and managed…. Victoria Ward will call

to handover and transfer patient 3. Patient 2 escorted in walks in and goes to chair he is left and thinks someone is

coming to give him his assisted wash – the wander guard is alarming . The porter arrives to take patient 3 to the discharge lounge will not leave (patient is

in another room). Patient 2 will need the assistance of 1 to supervise him. Patient 1 will still require on-going monitoring, reassessment and management Throughout the scenario there will be multiple other intrusions/problems that need

to be addressed (Use as many as required depending on how scenario is progressing)

STAGGER These and alternate staff to do roles if possible

Pharmacist looking for TTO Another nurse asking for help with a patient that has just had a fall Relative on phone asking when their mother is coming home Nurse from another ward asking for a catheter as they have run out



Patient 1 (SimMan)Patients Name: Albert Adams Patients Age / DOB: 80 year old maleMajor Problem

Clinical / MedicalUTI Sepsis

NTSTeam work / CommunicationSituational awarenessLearning

GoalMedicalRecognition + management of sepsis


Albert Adams, an 80 year old male, was admitted from home 3 days ago acutely confused and ‘off legs’. He was found to be in urinary retention with a UTI. He is now on oral antibiotics with a foley catheter insitu, and has been transferred to OPU for ongoing treatment and complete geriatric assessment. PMHx: AF and HTN DHx: Digoxin, Ramipril, NKDA Resus status: Full SHx: Lives with his wife and independent with ADLsDay 1: BP 165/95, HR 90 irregularly irregular, Sats 94% on air.Day 2: Made good progress initially and was transferring with one carer at lunchtime. Catheter became displaced and was reinserted that afternoon. That night he became disorientated and required a dose of haloperidol.Day 3: He has become increasingly disorientated. BP 110/75, HR 110 AF, Sats 96% on air. Decreased urine output noted overnight.

Staffing Faculty Control Room:1 x technician1 x patient voice1 x debriefer1 x nurse from acute ward

Faculty Role Players:1 x NA plant1 x Actor (Patient 2)1 x Actor/plant (Porter)1 x Actor/plant (Pharmacist)

Case Briefing To All CandidatesIt is a weekday on the ward. You have been asked to review Albert Adams, an 80 year old male, who has become increasingly confused overnight. He is now PAR scoring 4, and the HCA is concerned the patient looks unwell.

To Role Players:

Manikin preparation

Patient not attached to any monitoring but has IV access: 24G (pink) cannulaCatheter insitu, ideally with urometer which is empty

Room set up As per elderly care ward. Needs bed in second bay with chair beside it.

Simulator operation

Patient 1 (SimMan):Patient initially talking but confused and disorientated (MMTS 3/10). He becomes more agitated as he deteriorates. He improves if given fluids, Abx, O2 and appropriate de-escalation techniques used.Patient 2 (actor):Alert keeps lifting body weight off his wander guard so it keeps alarming. Does not wander, very quiet and answers questions when


asked. Restless and disorientated.

Props needed

Patient 1:Foley Catheter, urometer, dark stained urine, iv fluidsDrugs: Abx, paracetamolPatient 2 (actor):Wanderguard, pyjamas


Patient 1 (SimMan)Albert Adams, 80 year old male

Observations:Initial

In the first 5-10 minutes if untreated

In the next 5 minutes with treatment (iv fluids and abx)PAR score

HR 98 AF 0O2 sats 99% (100% with O2) 0BP 105/64 0Temp 37.9 C 1RR 18 0GCS E=4 V=4 M=5

Total=132

Total PAR Score 3


PAR scoreHR 110 AF 1O2 sats 96% RA 0BP 105/66 0Temp 37.9 C 1RR 22 0GCS E=4 V=4 M=5

Total=13Talking but confused

2

Total PAR Score 4

PAR scoreHR 115 AF 2O2 sats 97% (100% with O2) 0BP 93/56 1Temp 37.9 C 1RR 25 2GCS E=4 V=4 M=6

Total=132

Total PAR Score 8

BM = 7.4Capillary refill – 2 seconds

Routine bloods and ABG available if asked

MMTS 3/10Correct nameCorrect d.o.BCorrect monarch


Patient 1 (SimMan)Albert Adams, 80 year old male

ScenarioYou were admitted to hospital from home 3 days ago acutely confused and ‘off legs’. You were found to be in urinary retention with a UTI. You are now on oral antibiotics with a catheter insitu, and you have been transferred to the elderly care ward for ongoing treatment and a complete geriatric assessment.

PMHx: AF and HTNDHx: Digoxin, Amlodipine, NKDA Resus status: fullSHx: Lives with his wife, independent with ADLs, non-smoker, non-drinker

You initially made good progress and you were able to transfer with one carer yesterday lunchtime. Your catheter became displaced and was reinserted that afternoon. Overnight you have became increasingly disorientated and confused.

Underlying diagnosisUTI Sepsis / SIRS

InstructionsYou are scared and confused as you can see and hear everyone start to panic and run around. You know ‘Who you are’ but NOT where you are, what year it is or why you are in hospital.

If given a mini-mental test, you answer correctly your name, d.o.b. and the queen’s name only.

You are breathless with a sore ‘tummy’ and you want to go home to your wife and dog.You can only give a vague history and need constant reiteration of where you are and why.You know you are on a little white tablet for blood pressure.

.



Patient 1 (Manikin)ABG Result Albert Adams, 80 year old male

pH 7.32pCO2 3.8pO2 10.6 on airBE -5HCO3 20Lactate 4.4

Patient 1 (Manikin)Blood Results (from earlier in the day)Albert Adams, 80 year old male

Hb 10.2 Na 147WCC 14.5 K 5.3Plts 460 Ur 11

Cr 135



Surgical / Medical SpR/SNP on the Phone Role

ScenarioIt is a weekday on the ward. You have been asked to review Albert Adams, an 80 year old male, who has become increasingly confused overnight. He is now PAR scoring 4, and the NAA is concerned the patient looks unwell.

Underlying diagnosisUTI Sepsis / SIRS

InstructionsYou are not available to attend immediately.You want to know his history and current status (inc. observations and PAR score).You can advise appropriate investigations and management if it has not been administered and appropriate escalation (Patient will not need transfer to higher level care if managed appropriately).You will come and review as soon as you are able.



Patient 2 (actor)Patients Name: Robert Greycoat (‘Bob’)Patients Age / DOB: 78 year old maleMajor Problem

Clinical / MedicalPoor mobility. Visual impairment.

NTS Team work / CommunicationUtilising available resourcesLearning

GoalMedicalFalls assessment


‘Bob’ Greycoat was admitted via A&E 2 days ago with an acutely swollen and painful right knee. He was unable to get out of bed so the district nurse and the rapid assessment team visited and he was transferred to the ED for complete assessment.. The knee was aspirated and confirmed as a crystal arthropathy (gout). He has been commenced on colchicine and regular analgesia. He has long term diabetes - which he has problems managing and so the District nursing team support him. PMHx: HTN, #R NOF, Macular degeneration - NKDA Resus status: Full DHx: Bendroflumethiazide, Ramipril, Colchicine, Ibuprofen, Omeprazole SHx: Lives with his wife and ‘co-dependent’ with ADLs. Volunteers do the shopping and patient mobilises by furniture walking.Mr Greycoat is agitated and restless keeps lifting his weight off the wander alarm, when no-one looks his falls on the floor about 2/3rds of the way through the scenario.

Staffing Faculty Control Room:1 x technician1 x patient voice1 x debriefer1 x nurse from acute ward

Faculty Role Players:1 x NA plant1 x Actor (Patient 2)1x actor/plant (Patient 3)1 x Actor/plant (Porter)1 x Actor/plant (Pharmacist)

Case Briefing To All CandidatesNone

To Role Players:None

Manikin preparation

NonePatient 2 will be played by an actor.

Room set up As per ward. Needs bed in second bedspace with chair beside it.

Simulator operation

Patient 1:Patient initially talking but confused and disorientated (MMTS 3/10)He becomes more agitated as he deteriorates. Improves if given fluids, Abx, O2 and appropriate de-escalation techniques used.Patient 2 (actor):Patient agitated restless and disorientated.

Props needed

Patient 1:Foley Catheter, urometer, dark stained urine, iv fluidsDrugs: Abx, paracetamol


Patient 2 (actor): Chair, wander alarm, hospital gown, redness to knee


Patient 2 (actor)Robert Greycoat (‘Bob’)78 year old male

Observations (unless actor happy for it to be performed):

Patient 2 (actor)Blood Results (from earlier in the day)Robert Greycoat (‘Bob’)78 year old male

Hb 14.6 Na 138 Uric acid 12.4WCC 10.2 K 4.2Plts 326 Ur 11.3

Cr 123


PAR scoreHR 86 0O2 sats 98% RA 0BP 146/89 0Temp 36.2 0RR 20 0GCS E=4 V=5 M=6

Total=150

Total PAR Score 0


Patient 2Robert Greycoat (‘Bob’)78 year old male

ScenarioYou were admitted via A&E one day ago with an acutely swollen and painful right knee. Some fluid was drained from the knee and you have been told you have gout. You have been started on a new tablet and some pain-killers but you are still finding it very difficult to walk and get in and out of the chair. You have had some difficulty getting around since you fractured your right hip 6 years ago. You live in a ground floor flat with your wife who you are co-dependent on for your ADL’s although your children help you with shopping. You get around the house by holding on to the furniture. In addition, you know your sight is getting worse and you are now having trouble reading. The district nurses visit you daily to give you your insulin injection.

PMHx: IDDM, HTN, #R NOF, Macular degeneration Resus status: Full DHx: NKDA. Bendroflumethiazide, Ramipril, Colchicine, Ibuprofen, Omeprazole SHx: Lives with his husband/wife and ‘independent’ with ADLs.

You have just been transferred to another ward, you have not been told why or where.

Underlying diagnosisGoutPoor mobilityVisual impairment

Instructions

You want to go to the toilet but you have moved wards today and don’t know where it is.You are finding it difficult to stand and walk due to the pain in your right knee. You will need the assistance of 1 and reassurance to mobilise. You keep getting up so the wanderguard goes off. 2/3rds of the way through the scenario you get up and fall.



Victoria Ward Phone Call

Scenario‘Chris’ Henry was admitted via A&E 2 days ago with heart failure. She was commenced on a GTN infusion and regular furosemide, the infusion was stopped this morning. She has long term mobility problems following a previous #humerus 2 years ago and no current POC. She has therefore been transferred for complete geriatric assessment.

PMHx: previous MI (unsuitable for stenting awaiting CABG), CCF, HTN, high cholesterol, #R humerus, long-term smoker

DHx: Allergic to penicillinOn GTN spray, furosemide, aspirin, clopidogrel, atenolol, simvastatin, ad cal, alendronic acid, omeprazoleSHx: Lives with his son and is ‘independent’ with ADLs. Family do the shopping.

Underlying diagnosisCCF – heart failure

InstructionsYou call the ward (3-5minutes into scenario). You have been informed by the bed manager that a bed is available and ready on the ward for your patient. You have been told to transfer him ASAP as you are desperate for beds on your ward. You want to do a phone handover of the patient, as your ward can’t spare staff at this time.



Porter

ScenarioYou have been asked to transfer a patient (Mr Singh) to the discharge lounge but you need assistance to transfer him to the wheelchair. The patient is not in the high fidelity room but on a side room outside.

InstructionsYou are unable assist in transferring the patient as you are not trained in manual handling.You are currently extremely busy and need your wheelchair back to do another transfer. If no one comes to assist in getting Mr Singh into the chair you will ask to use the phone to ring your supervisor to let them know you have been delayed.



Pharmacist

ScenarioIt is a busy day on the elderly care unit. Mr Adams, an 80 year old gentleman has become acutely unwell and delirious. In addition, a new patient admission from Victoria Ward has arrived with a porter and s/he needs admission by the nursing staff.

You are very quickly trying to finish off the TTO for another patient who is due for discharge today (Mrs Betty Hutchins) after some last minute changes were made on the ward round this morning. The discharge lounge porter has already arrived to take the patient down.

InstructionsYou cannot find the drugs that had already been prepared in order to amend the TTO. You have checked the patient’s locker and the drug cupboards and cannot find them. The discharge lounge porter has arrived to take the patient down. You would like some help trying to find them please.

Staff nurse from another bay

Scenario

You are a staff nurse on the ward who is looking after one of the other bays. On of your patients tried to stand up from the chair and has fallen over. You need some assistance to get them up and have come looking for help.

InstructionsYou need a second person to help you pick up this patient as they may need a hoist. The patient is complaining of pain in their leg and you are concerned they have injured themselves. You want someone to help you ASAP.



Relative on phone

ScenarioIt is a busy day on the ward. Mr Adams, an 80 year old gentleman has become acutely unwell and delirious. In addition, a new patient admission from Victoria Ward has arrived with a porter and s/he needs admission by the nursing staff.

Your mother was due to be discharged home from the ward today and you have taken the day off work to met her when she comes home to ensure she gets settled in. You were under the impressions she was due to be discharged this morning but she has not yet arrived home. You have rung the ward to find out where she is.

InstructionsYou are annoyed that your mother is not yet home as you have taken the whole day off work to wait for her. You want to know where she is and when she is likely to arrive.

Staff nurse from another ward

Scenario

You are a staff nurse from another ward and you need a male catheter as you have run out. You have just started and you have not yet been given access to the omnicell so you need someone to come and get the catheter for you.

InstructionsYou need someone to get a male catheter for you ASAP as you patient has gone into retention and the doctor is waiting to insert the catheter.


Delirium and Dementia – Simulation Scenario 3 – Busy Ward Staff Nurse Plant Role

ScenarioIt is a busy weekday on the ward. There are 3 issues in play:

1. Bob Greycoat, a 78 year old man who is agitated and restless, his Nurse & OT have been utilising the wanderguard system which is alarming constantly and then falls when no-one is looking.

2. Albert Adams, an 80 year old man, has become acutely unwell and delirious, PAR scoring 4.

3. Victoria ward needs to transfer a patient over ASAP who will require admission by the nursing staff (including STRATIFY falls assessment and a phone call to relatives as per guidelines).

4. The pharmacist is trying to urgently prepare a complex TTO for a patient who is due to be discharged today. The discharge lounge porter has arrived to collect the patient, but the TTO cannot be found.

Patient 1 (SimMan):Your patient, Albert Adams, an 80 year old male, was admitted from home 3 days ago acutely confused and ‘off legs’. He was found to be in urinary retention with a UTI. He is now on oral antibiotics with a foley catheter insitu, and has been transferred to OPU for ongoing treatment and a complete geriatric assessment.

PMHx: AF and HTN DHx: Digoxin, Ramipril, NKDA Resus status: full SHx: Lives with his wife, independent with ADLs, non-smoker, non-drinker

Day 1: BP 165/95, HR 90 irregularly irregular, Sats 94% on air.Day 2: Made good progress initially and was transferring with one carer at lunchtime. Catheter became displaced and was reinserted that afternoon. That night he became disorientated and required a dose of haloperidol.Day 3: He has become increasingly disorientated. BP 110/75, HR 110 AF, Sats 96% on air. Decreased urine output noted overnight.

On routine obs, you note he appears more unwell and confused. You have called for help.

Underlying diagnosisUTI Sepsis / SIRSPatient 2 (actor):


Alert keeps lifting body weight off his wander guard so it keeps alarming. Does not wander, very quiet and answers questions when asked. Restless and disorientated eventually falls on to the floor.

Call about Patient 3 (actor/ plant ):3-5 minutes into the scenario, Victoria ward will call requesting to urgently transfer a patient to the OPU. They will handover the patient over the phone. A porter needs the assistance of 1 to transfer another patient to the discharge lounge.


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