CC âI came here because it is hard for me to breath and my stomach hurts, I ... âI have done IV drugs but none in yearsâ All else negative: âno fever, chills, burning.
Building a Culture of Safety for Healthcare Professionals Leann Horsley, PhD, RN, CHSE, CNE Trent Reed, DO, FACEP Donna Quinones, BS, CHSE Viva Siddall, RRT, MS, CHSE Marcie Calandra, DNP, MS, CNS, APRN‐BC Keith Muccino, SJ, MD William Adams, PhD
ANCC Continuing Nursing Education
International Nursing Association for Clinical Simulation & Learning is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. @INACSL | #INACSL18
Disclosures • Conflict of Interest • All authors report no conflict of interest • Julia Greenawalt (INACSL Conference Administrator & Nurse
Planner) reports no conflict of interest • Erin Killingsworth (INACSL Nurse Planner) reports no conflict of interest
• Successful Completion • Attend 100% of session • Complete online evaluation
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Learning Outcomes Upon completion of this educational activity, participants will be able to: 1.
Identify TeamSTEPPS resources available through AHRQ
2.
Discuss potential opportunities for interprofessional TeamSTEPPS simulation training within their institutions
3.
Identify essential criterion for simulation‐enhanced interprofessional education to meet the INACSL Standards of Best Practice: Simulation @INACSL | #INACSL18
INACSL Standards of Best Practice: Simulation Simulation‐Enhanced Interprofessional Education (Sim‐IPE) Criteria 1.
Conduct Sim‐IPE based on a theoretical or a conceptual framework
2.
Utilize best practices in the design and development of Sim‐IPE
3.
Recognize and address potential barriers to Sim‐IPE
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Background & Significance
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Literature Review & Theoretical Framework • IOM 1999 To Error is Human • IOM 2003 Quality Chasm Report • AHRQ/DOD TeamSTEPPS 2006 • IPEC Core Competencies 2011, updated 2016 • Simulation environment • Healthcare environment • Culture of Safety • NLN Jeffries Simulation Theory
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Research Questions 1.
What is the effect of the TeamSTEPPS simulation training on the health care professionals’ knowledge of the TeamSTEPPS principles?
2.
What is the effect of the TeamSTEPPS simulation training on the health care professionals’ perceptions of safety?
3.
What is the effect of the TeamSTEPPS simulation training on the health care professionals’ team performance?
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Research Design • Quantitative Descriptive • One group pretest‐posttest design • Intervention – TeamSTEPPS simulation training
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Sample & Setting • N = 70 Health care professionals – physicians, nurses, patient care
technicians, allied health, and administration • Convenience sample with random assignment to groups • Simulation environment in an academic setting • IRB – exempt status
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Instruments • Demographic questionnaire • 7‐items • Simulation Using TeamSTEPPS to Promote Interprofessional
Education and Collaborative Practice • • •
14‐items multiple choice quiz Knowledge of TeamSTEPPS principles Agency for Healthcare Research and Quality & Department of Defense
• TeamSTEPPS Teamwork Perceptions Questionnaire (T‐TPQ) • 35‐items questionnaire on a 5‐point Likert scale ranging 1‐5 • Perception of team performance and safety • Agency for Healthcare Research and Quality & Department of Defense • Team Performance Checklist • 11‐items, dichotomous scale • Team performance @INACSL | #INACSL18
Simulation Using TeamSTEPPS to Promote Interprofessional Education and Collaborative Practice 1.
Research into the root causes of treatment errors have led us to prioritize and address the problem of: a) b) c) d) e)
2.
Outdated equipment Physician shortages Third party reimbursements System breakdowns Restricting foreign medical graduates
A nurse is very concerned about a baby that she is taking care of and feels it would be best to have the attending pediatrician come to the bedside immediately to evaluate. Checking around the unit, she locates the pediatrician who is busy dictating a consultation. The nurse’s BEST action is to: a) b) c) d) e)
Wait quietly, tapping her foot rhythmically to indicate urgency. Quickly explain the infant’s worrisome appearance, and state “I need you right now!” Walk away, with a plan to check back with the pediatrician in a few minutes. Interrupt by shaking the doctor’s shoulder and pull her quickly toward the patient’s crib. Ask the unit clerk to page the pediatrician with instructions to call the nurse on the unit.
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TeamSTEPPS Teamwork Perceptions Questionnaire (T‐TPQ)
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Team Performance Checklist
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Evaluator Training • Orientation
Methodology • Simulation scenarios • Instruments •
• Initial video training • Monthly training •
Interrater reliability
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Simulation Scenario #1 State Name
Patient Status (VS, ABG, BS, Eyes)
Physiology Present
Learning Outcomes or Desired Actions
Time in State Or Transitions Patient Name: Sarah Peters 20 year old WF
Script
Phase 1 Standard Man Baseline
Standard man settings BS normal Eyes Blinking Wig, dressed in layers of dirty clothing, track marks from drug use
Introduction to simulated 3‐5 minutes environment
Introduction to room, equipment Manikin (Pre Brief) Brief report 2 minutes for Participants to coordinate team. Setting is emergency department. Prompt “Is anyone going to help me?
Phase 2‐ Onset
HR 100 B/P 124/84 RR 24 O2 Sat 92% RA Temp 98.6° F BS bilateral wheeze Eyes Blinking
Gather H&P Obtain VS Place IV Order Labs Order X‐ray Order EKG Order Ultrasound
CC “I came here because it is hard for me to breath and my stomach hurts, I keep bleeding.” General Survey: pursed lip breathing, orthopnea, abdomen slightly distended, blood clots on pad Mental status: Orientated and somewhat anxious HPI: Pain: “My stomach hurts in middle part of stomach” 8/10 “ I have been bleeding for few days, worse this morning” “I need to change pad often” SOB: “I always get like this when the weather gets warm and the flowers are growing” Psych: “used to take pills for my head, I ran out” “no suicidal or homicidal thoughts, no hallucinations, yes I sleep ok, no racing thoughts” “I feel anxious can I get something to calm me down?” Track Marks: “I don’t know what these marks are from, people tell me they are track marks but whatever.” “I have done IV drugs but none in years” All else negative: “no fever, chills, burning on urination, nausea, or vomiting” PMH: dx asthma when little, “doc said I was bipolar” FMH: “don’t have any family” Med/Social HX: “I go to hospital when I can’t breathe, they give me something that smokes” “I smoke when I can get cigarettes” “I eat at soup kitchen or when people give me something” “I have a boyfriend” Last date of menstruation: “I don’t know” PE: mild tenderness over lower pelvic area remarkable during pelvis examination, moderate active bleeding in vaginal vault with cervical os open, no tenderness obs, BS bilateral exp wheeze, mild retractions Remainder of exam unremarkable.
Phase 3‐ treatment
HR 110 B/P 140/84 RR 30 O2 Sat 96% 2‐4L NC BS wheeze Bilateral Eyes blinking
Phase 4‐ stablized
HR 100 B/P 124/84 RR 18 O2 sat 98% RA BS clear Eyes Blinking
Vaginal bleeding Bronchospasm Hypoxia
Stabilized Bronchospasm resolves
manual
1L NaCl manual Apply O2 then sats rise Administer Nebulizer, benzodiazepine (lorazepam or alprazolam PO or lorazepam IV), RhoGAM (50 or 300 mcg)
Lab results: WBC 10,000 uL, Hbg 9.7 g/dL, HCT 27.7%, Plt 250; Chem and urine WNL, Blood Type B Rh‐, b‐hCG 9400 mIU/mL, (elevated suggest 3‐4 wks gestational age) Chest X‐ray: flatten diaphragms, translucent lung fields Ultrasound: abnormal gestational sac within cervical canal Urine: Pregnancy test positive, blood in UA otherwise normal EKG: sinus tachycardia
Consults: OBGYN (Challenge) D&C Psych Bipolar SW homeless status
“I can breathe easier” “Are you going to give me one of those squirt things to take with me? They always do, they are yellow or blue” If a prompt is needed for the challenge: Emergency Department Charge Nurse enters the room and says: “the waiting room is full, we need to get this patient moving. Do you want me to make the call to the consult so you can talk with them?” Surgery Consult (strict tone, short temperament, cuts off caller halfway through): surgery vs. expectant management (CUS) “I have a busy schedule today and it is not ideal to talk now, can I call you back in 3 hours” Pause after challenge “ I guess you are right, I will be down to evaluate” Debrief team for 2 minutes prior moving to debrief with faculty.
end
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Simulation Scenario #2 State Name
Patient Status (VS, ABG, BS, Eyes)
Phase 1 Standard Man Baseline
Standard man settings BS normal Eyes Blinking Tied to bed with wrist restraints
Phase 2‐Onset
HR 126 B/P 95/60 RR 24 O2 Sat 92% RA Temp 98.6° F BS crackles wheeze R Eyes Blinking
Phase 3‐PEA Arrest
HR ‐ B/P ‐/‐ RR ‐ O2 Sat ‐ BS ‐ Eyes closed Monitor: ST (PEA)
Phase 4‐ stablization
HR 65 NSR B/P 85/45 RR 8 O2 sat 96% BS clear Eyes closed BS diminished
Physiology Present
Learning Outcomes or Desired Actions
Time in State Or Transitions Introduction to simulated 3‐5 minutes environment
Gather H&P Obtain VS Hyperventilation with Place IV X2 Hypoxia Order Labs‐ABG Order X‐ray Order EKG TX: Fluids, O2 NRB
CPR initiated Code called BVM‐Intubation Medications: epi, tPA (10mg IV bolus followed by 90mg over 2 hours) Hs & Ts ACLS 5‐7minutes
ROSC
Script Patient Name: Ed Powers 76 year old WM Introduction to room, equipment Manikin (Pre Brief) Brief report 2 minutes for Participants to coordinate team. Setting is a medical/surgery unit. Prompt “Is anyone going to help me? [Pt fractured ankle from fall 2 days ago. Patient waited over 10 hours in the ER waiting admission. NPO since midnight awaiting surgery today. Keeps getting bumped from OR slot. Pt keeps trying to get up for the past couple of hours and it became a safety concern, no sitters available and no sedation so patient was put in wrist restraints for his protection.]
manual
CC “hard to breathe, right side of my chest hurts when I breathe, dizzy.” General Survey: pursed lip breathing, cough, orthopnea, anxious, neck veins slightly distended, blood tinged sputum in cup Mental status: A&O X3 HPI: Pain: “sharp R side 10/10” SOB: “I get SOB ” “no fever, chills, burning on urination, nausea, or vomiting” “my R ankle hurts plus it’s now hurting up into my calf” PMH: no surgeries, hospitalized x3 exacerbation COPD on BiPAP FMH: “my wife died 4 years ago” “no children I live alone” CHS:” “I smoked 1x60 yrs” “Mailman for 45 yrs” “Couple Inhalers for now maybe O2 in the future doc said” PE: remainder of exam unremarkable. BS R crackles RLL, wheeze “Tired of waiting for surgery and I just want to get up” “ I don’t feel well” Move to next stage PEA ARREST
manual
Lab results: WBC 11, Hgb 13, Hct 40%, Plt 250; PT 12 (10‐14), PTT 30 (20‐40) ABG: pH 7.51, CO2 28, PO2 39, HCO3 21 RA Chest X‐ray: increased radiolucency R, flatten diaphragm, R atelectasis 5 min into code control room call from radiology “hi are you the team caring for Ed Powers? I am looking at his CT, the radiology resident missed the PE, he has a PE” Whether or not Thrombolytic given Move to ROSC/Stabilization Patient moans slightly as he begins to come around.
Consults: ICU transfer (Challenge)
If additional prompt is needed for the challenge a nursing supervisor will enter the room and say: “This patient is way too sick for the floor. Do you want me to call ICU for you to talk with them about getting a bed?” If Cardiology Consult is made: “Go ahead and transfer the patient to the ICU. I’m headed that way now and will be there in a couple of minutes.” ICU Consult: Request for bed transfer to critical care service (CUS) “We are slammed right now. All of the nurses are providing 1:1 care for patients on ventilators. We have vacant dirty room but would need those cleaned plus more nurses. I don’t know when I can get back to you on this, much later okay? Pause after challenge “I guess you are right, we’ll make some adjustments to get this patient in the unit within the next half hour.” Debrief team for 2 minutes prior moving to debrief with faculty. end
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PRE‐TEST
Data Collection
One week prior to session Demographic questionnaire, TeamSTEPPS® Knowledge test, and T-TPQ
INTERVENTION Asynchronous TeamSTEPPS® e‐module
Prebrief
Simulation Scenario #1 Team Performance Assessment then Structured Debriefing
Reinforced Learning Discussion
Simulation Scenario #2 Team Performance Assessment then Structured Debriefing
POST‐TEST TeamSTEPPS® Knowledge test, T‐TPQ, and Session evaluation
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Demographics Valid N / % Sex Male Female Race Asian
68 7 61 / 90% 69 11
Black
6
Hispanic
14
White
34 / 49%
Other
4
Profession
69
Medicine
10
Nursing
39 / 57%
Other Years of Experience 22 Years
23
Prior TeamSTEPPS Training No Yes Prior Simulation Experience No Yes Prior Inter‐professional Education
69 65 / 92% 4 69 48 / 70% 21 69
No
30
Yes
39 / 57%
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Results – Research Question 1 • What is the effect of the TeamSTEPPS simulation training on the
health care professionals’ knowledge of the TeamSTEPPS principles?
Overall
Valid N
Mean Difference
69
0.71
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95% Confidence Interval Lower Upper 0.23 1.19
p .005
Results – Research Question 2 • What is the effect of the TeamSTEPPS simulation training on the
health care professionals’ perceptions of safety? Event Valid N
Pre‐Simulation
Post‐Simulation
p
Mdn
Q1
Q3
Mdn
Q1
Q3
The skills of staff overlap sufficiently so that work can be shared when necessary.
70
3
3
4
4
3
4
.001
My unit makes efficient use of resources (e.g., staff supplies, equipment, and information).
70
3
2
3
3
3
4
.01
My unit has clearly articulated goals.
70
3
3
3
3
3
4
.01
My unit operates at a high level of efficiency.
70
3
2
3
3
3
4
.02
My supervisor/manager takes time to meet with staff to develop a plan for patient care.
70
3
2
3
3
3
4
.048
Staff effectively anticipate each other’s needs.
70
3
2
3
3
3
4
