TABLE OF CONTENTS
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Enhancing Registered Nurse Job Readiness and Patient Safety Outcomes Through Clinical Simulation
Simulation Scenario MULTIPLE PATIENTS TRAUMA
Adaptation of California Simulation Alliance (CSA)
February 24th, 2014
Revised April 2014
University of Ottawa
Algonquin College
Susan Eldred
Heather Macmillan
Shawna Watt
SECTION I SCENARIO OVERVIEWA. / Title
B. / Summary
C. / Evidence Base
SECTION II CURRICULUM INTEGRATION
A. / Learning Objectives
- Primary
- Secondary
- Critical Elements
B. / Pre-scenario learner activities
SECTION III SCENARIO SCRIPT
A. / Case Summary
B. / Key Contextual Details
C. / Scenario Cast
D. / Patient/Client Profile
E. / Baseline patient/client simulator state
F. / Environment / equipment / essential props
G. / Case flow /triggers / scenario development
SECTION IV APPENDICES
A.
B.
C. / Health Care Provider Orders
B. Digital Images of Manikin / Milieu
Debriefing Guide/Patient Scripts
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
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SECTION I: SCENARIO OVERVIEW
Scenario Title: / Multi-patient Trauma: Multiple Vehicle CollisionOriginal Scenario Developer(s): / University of Ottawa
Shelley Clarke, Susan Eldred, Heather Macmillan, Shawna Watt
Date - original scenario / February, 2014
Validation:
Revision Dates:
Pilot testing:
QSEN revision:
Estimated Scenario Time: 30-40 min Debriefing time: 45-60 min
Target group:4th year students-Complex Care, new grads
Core case:Maternal and fetal assessmentR/O vaginal bleeding, R/O head injury, Splenic laceration
CNO/ CPSI/CIHC:
- Patient Safety
- Teamwork and Collaboration
- Competencies for Entry-level Registered Nurse Practice:
Competent Application of Knowledge
- Interprofessional Communication
- Client Centered Care
This is a multiple patient scenario involving 3 patients in the Observation Unit following an MVC.
Patient A: R/O fetal distress/injury
Patient B: R/O Head Injury
Patient C: Splenic Laceration
Patient A is a 35 y.o. mother, 19 weeks pregnant that was driving herself and her pre-school son to a clinic appointment when she was in a collision. She has a sprained wrist but otherwise appears to be stable. There is currently no evidence of vaginal bleeding. She is under observation prior to being cleared for discharge. Maternal/fetal assessment to R/O fetal distress/injury.
PatientB is Patient A’s 3y.o. son. He was restrained in a child car seat and shows a mild abrasion to his forehead from the impact during the collision. He is stable and is under observation prior to being cleared for discharge. R/O head injury.
Patient C is 42 year old man. He was a restrained driver that was struck by another vehicle. The other vehicle struck thedriver’s side door with about 2 feet of intrusion into the passenger compartment. He had a brief loss of consciousness but is now alert and conversant. Hecomplains of left shoulder and chest painand left upper quadrantabdominal pain.He is under observation, awaiting results from XRay and CT.
In this scenario learners are to prioritize and organize care in order to manage the various needs of the patients. They must accurately assess all 3 patients and recognize the signs of hypovolemic shock in Patient C in order to intervene effectively. Interventions should include:
Patient A: Fetal heart rate monitoring with a Doppler, interpretation of lab results.
Patient B: neurological assessment, orientation to 3 spheres
Patient C: positioning, apply O2, reassessing abdomen and circulatory system, recognizing need for further orders, communicating with the healthcare team and IV bolus.
EVIDENCE BASE / REFERENCES (APA Format)
American Academy of Pediatrics and Pediatric Orthopedic Society of North America. (2008). Management of Pediatric Trauma. 121 (4).
Babb, M. et al., January 2010. Treating Pain During Pregnancy. The Hospital for Sick Children-Motherisk. Retrieved February 14th, 2014, from
College of Nurses of Ontario (2014).Competencies for entry level registered nurse practice(41037). Retrieved from CNO website:
Freiwald, S. (2010). Late presenting complications after splenic injury. The Permanente Journal. 14(2).
Pagana,K. (2011).Mosby's diagnostic and laboratory test reference(10thed.). St. Louis, MO: Elsevier.
Perinatal Partnership Program of Eastern Ontario. (2007). Care of the pregnant trauma patient. Retrieved from A classic in the field.
Perry, S.E. (2013). Maternal Child Nursing Care in Canada. Toronto: Mosby Canada.
Schulman, C. (2003). A FASTer method of detecting abdominal trauma. Nursing Management. 34 (9). A classic in the field
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14) SECTION I
ALL DATA IN THIS SCENARIO IS FICTICIOUS
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SECTION II: CURRICULUM INTEGRATION
A. SCENARIO LEARNING OBJECTIVESDo What / With What / For What
- Students will perform
- Students will accurately interpret
- Students will respond to changes in patient status
- Students will be able to coordinate the care of the three patients
- Students will apply knowledge and skills
B. Learning Outcome Assessment / Rubric
Competency
(based on “What For”) / Demonstrated attributes align with required competency / Demonstrated attributes need some improvement to align with required competency / Demonstrated attributes need major improvement to align with required competency
- Students will appropriately utilize assessment findings, patient history and lab results to organize and prioritize the care of multiple patients.
-seeks out report and clarifies information as needed
-creates shift work-sheet to organize care
-seeks to identify and assess priority patient first / -reviews MAR and listens to report but seeks no further information
-creates shift work-sheet but key information is not listed (med times, needed tests etc)
-priority patient is eventually identified and assessed / -relies on report for all relevant information
-no shift work-sheet created
-no identification and/or assessment of a priority patient
- Students will respond to changes in patient status by communicating with the physician in order to intervene effectively.
-communicates effectively (SBAR) sharing all relevant information and status changes
-transcribe new orders
-implement new orders / -contacts the MD
-communication is disorganized (no SBARR) but shares relevant information re: status change
-implements new orders but fails to transcribe / -contacts MD
-fails to communicate relevant information and communication is extremely disorganized
-no follow through on new orders
- Students will be able to coordinate the care of 3 patients with other care providers to ensure the safe and timely delivery of care.
-effective communication is established amongst team members (sharing of assessment findings, response to interventions, patient concerns etc)
-Effectively communicates with patient throughout simulation to keep informed, relieve anxiety and support
active participation in care as able
-patient safety is maintained throughout / -delegation of tasks, assessments and interventions occurs but in a disorganized fashion
-communication amongst team members is disorganized or incomplete
-communication with client(s) is minimal
-overall safety of the patient is maintained / -little to no delegation occurs
-lack of communication
-patient safety is of concern
- Students will apply knowledge and skills acquired from previous laboratories, theory and clinical in order to manage the care of a pediatric, a pregnant and a trauma patient.
- Identifies and interprets significant assessment findings requiring immediate reporting and/or intervention
-Accurately prioritizes immediate interventions required for a patient with an unexpected change in status. / -assessments are completed but are disorganized
-recognizes abnormal assessment findings but fails to communicate them in an appropriate period
-struggles with the organization and prioritization of care / -assessments are incomplete or irrelevant
-fails to recognize abnormal assessment findings/changes in patient status
-little to no organization or prioritization evident
C. PRE-SCENARIO LEARNER ACTIVITIES
Prerequisite Competencies
Knowledge / Skills/ Attitudes
Pathophysiology, risk factors, assessment techniques and treatment of fetal injury/distress, head injury and abdominal trauma / Communication with interprofessional team
- Use SBAR method
Communication with pediatric, acutely ill and/or anxious patients & members of the healthcare team / Strategies for decreasing anxiety & ensuring active patient participation
Principles of teamwork and collaboration / Neurological Assessment
- GCS
Dimensions of patient centered care / Fetal Assessment
fetal heart rate monitoring
pelvic/fetal palpation
Patient safety principles / Abdominal Assessment
- Auscultate bowel sounds (first)
- Palpate for rigidity, distension (following auscultation)
Assess Vital Signs
- Complete temperature, pulse, respirations, blood pressure and oxygen saturation
Collaborative interventions / changing pt status; hypovolemic shock
SECTION III: SCENARIO SCRIPT
A.Case summary-Patient A35 y.o. female; 19 weeks pregnant. Driving to a clinic to have her left wrist examined following a fall this AM. She was brought in to ER via ambulance following a 2 car collision involving her and her 3 y.o. son and another vehicle. She reports no pain (other than her wrist) and is in observation to R/O fetal distress and vaginal bleeding and to monitor FHR. Learners are expected to perform a shift assessment. Upon approaching the bedside, they find herin another bed with her pre-school son.
Learners are expected to: check VS, O2 sat, FHR via Doppler, ask about any vaginal bleeding, assess for pain (PQRST), communicate effectively (therapeutic communication), provide support and teaching as well as to encourage the patient to remain in the assigned bed. Students should also recognize that this patient is stable and is of lower priority at this point.
B. Key contextual details-Patient A
Scenario takes place on the Observational Unit attached to the ER during day shift. The patient has been triaged and is being observed prior to being cleared for discharge. The students will receive report from the ER nurse transferring care to the Observation Unit. X-ray of L wrist shows no fracture and is being treated as a sprain. Urinalysis results are normal. CBC, K-B assay are all normal as well.
Patient is anxious regarding the status of her unborn fetus and also regarding her 3 y.o. son. She doesn’t want to be far from her son as he is crying for her and wanting her for comfort.
C. Scenario Cast – Patient A
Patient/ Client / High fidelity simulator-Patient B & C
Mid-level simulator
Task trainer
Hybrid (Blended simulator)
Standardized patient-Patient A
Role / Brief Descriptor
(Optional) / Confederate/Actor (C/A) or Learner (L)
RN 1-Primary Nurse / Assessment and delegation; communication / Learner
RN 2-New Grad / Administration of meds, verifies lab results, checks orders, follows direction from RN 1 / Learner
Charge Nurse / May be used as a resource / Confederate
Documenting Nurse / Documentation / Learner
Pt B and C / Voices of patients / Confederate/Actor
D-1. Patient/Client Profile-Patient A
Last name: / Rodriguez / First name: Julia
Gender: F / Age: 35 / Ht: 167cm / Wt: 60kg / Code Status: Full
Spiritual Practice: None identified / Ethnicity: Caucasian / Primary Language spoken: English
1. Past history
Patient fell this AM catching herself with her left hand. She had severe pain to wrist and was driving to clinic appointment when she collided with another vehicle. Her 3 y.o. son was in the car with her. She was brought in to ER via ambulance and is being observed before being cleared for D/C. X-ray shows no fracture to wrist. Being treated as a sprain.
G: 2, T: 1, P: 0, A: 0, L: 1. Currently 19 weeks pregnant. No complications to date. No complications with previous pregnancy. Saw OB earlier in the week.
Primary Medical Diagnosis / R/O Vaginal Bleeding R/O fetal distress
2. Review of Systems
CNS / Alert & oriented x 3; anxious
Cardiovascular / WNL
Pulmonary / WNL
Renal/Hepatic / No complaints of urinary difficulty; no evidence of hematuria
Gastrointestinal / WNL
Endocrine / WNL
Heme/Coag / No sign indicative of a bleed; Hgb slightly low but in keeping with pregnancy
Musculoskeletal / Normal except swelling/pain in left wrist
Integument / WNL
Developmental Hx / WNL
Psychiatric Hx / None shared
Social Hx / Married x 5 years; husband is in the military and is currently away; mother; 2nd pregnancy; stay at home mom
Alternative/ Complementary Medicine Hx / None shared
Medication allergies: / None / Reaction:
Food/other allergies: / None / Reaction:
3. Current medications / Drug / Dose / Route / Frequency
Acetaminophen / 650mg / PO / Q4-6h PRN for pain
Ibuprofen / 200-400mg max 1200mg/day / PO / Q6h PRN for pain
4. Laboratory, Diagnostic Study Results
Na: / K: / Cl: / HCO3: / BUN: / Cr:
Ca: / Mg: / Phos: / Glucose: / HgA1C:
Hgb: 110g/L / Hct: 35% / Plt: / WBC: 7 x 109/L / ABO Blood Type: O+
PT: / PTT: / INR: / Troponin: / BNP:
ABG-pH: / paO2: / paCO2: / HCO3/BE: / SaO2: 98% R/A
VDRL: / Kleihauer-Betke Assay: 0.6% / Herpes: / HIV: / X-ray (wrist): no fracture / EKG: WNL
E. Baseline Simulator/Standardized Patient State – Patient A
(This may vary from the baseline data provided to learners)
1. Initial physical appearance
Gender: Female / Attire:Street clothes, maternity pants and top
Alterations in appearance (moulage): slight baby bump
X / ID band present, accurate / ID band present, inaccurate / ID band absent or not applicable
Allergy band present, accurate / Allergy band inaccurate / Allergy band absent or N/A
2. Initial Vital Signs Monitor display in simulation action room: Patient A
No monitor display / X / Monitor on, but no data displayed
Display VS when learner takes them / Monitor on, standard display
BP: 138/78 / HR: 96 / RR: 14 / T: 37.2 / SpO²: 98% r/a
CVP: / PAS: / PAD: / PCWP: / CO:
AIRWAY: / ETC0²: / FHR:
Lungs:
Sounds/mechanics / Left: clear / Right: clear
Heart: / Sounds: S1S2
ECG rhythm: sinus
Other:
Bowel sounds: / Present WNL / Other:
3. Initial Intravenous lineset up
X / Saline lock #1 / Site: / R a/c / Y / IV patent (Y/N)
IV #1 / Site: / Fluid type: / Initial rate: / IV patent (Y/N)
Main
Piggyback
IV #2 / Site: / Fluid type: / Initial rate: / IV patent (Y/N)
Main
Piggyback
4. Initial Non-invasive monitors set up
NIBP / ECG First lead: / ECG Second lead:
Pulse oximeter / Temp monitor/type / Other:
5. Initial Hemodynamic monitorsset up
A-line Site: / Catheter/tubing Patency (Y/N) / CVP Site: / PAC Site:
6. Other monitors/devices
Foley catheter / Amount: / Appearance of urine:
Epidural catheter / Infusion pump: / Pump settings:
X / Doppler at bedside for fetal HR / Internal / External
Environment, Equipment, Essential props - Patient A
Recommend standardized set ups for each commonly simulated environment
1. Scenario setting: (example: patient room, home, ED, lobby)
Observation unit, ED; multi-bed ward. Bed 3.
2. Equipment, supplies, monitors
(In simulation action room or available in adjacent core storage rooms)
Bedpan/ Urinal / Foley catheter kit / Straight cath. kit / Incentive spirometer
IV Infusion pump / Feeding pump / Pressure bag / Wall suction
Nasogastric tube / ETT suction catheters / Oral suction catheters / Chest tube kit
Defibrillator / X / Code Cart / 12-lead ECG / Chest tube equip
PCA infusion pump / Epidural infusion pump / Central line Insertion Kit / Dressing ∆ equipment
IV fluid Type: / IV fluid additives: / Doppler / Blood product
ABO Type:
# of units:
3. Respiratory therapy equipment/devices
Nasal cannula / Face tent / X / Simple Face Mask / Non re-breather mask
BVM/Ambu bag / Nebulizer tx kit / Flowmeters (extra supply)
4. Documentation and Order Forms
X / Health Care Provider orders / X / Med Admin Record / H & P / X / Lab Results
Progress Notes / X / Graphic record / Anesthesia/PACU record / ED Record
Medication reconciliation / Transfer orders / Standing (protocol) orders / ICU flowsheet
X / Nurses’ Notes (blank) / Dx test reports / Code Record / Prenatal record
X / Actual medical record binder, constructed per institutional guidelines / Other
Describe:
5. Medications (to be available in sim action room) – Patient A
# / Medication / Dosage / Route / # / Medication / Dosage / Route
4 / Acetaminophen / 650mg / PO / 4 / Ibuprofen / 200-400mg / PO
D-2. Patient/Client Profile-Patient B
Last name: / Rodriguez / First name:Brendan
Gender: M / Age: 3 / Ht: 97cm / Wt: 14.7kg / Code Status: Full
Spiritual Practice: None identified / Ethnicity: Caucasian / Primary Language spoken: English
1. Past history
Patient was restrained in a child seat in the rear seat of the vehicle when it collided with another vehicle. His mother was the driver. He and his mother were brought in to ER via ambulance. Examination at the scene of the accident showed an abrasion to the forehead. He is being observed for any changes in status before being cleared for D/C.
Primary Medical Diagnosis / R/O Head Injury
2. Review of Systems
CNS / Alert & oriented x 3; anxious
Cardiovascular / WNL
Pulmonary / WNL
Renal/Hepatic / WNL
Gastrointestinal / WNL
Endocrine / WNL
Heme/Coag / WNL
Musculoskeletal / Normal except swelling/pain to injured area on forehead
Integument / WNL
Developmental Hx / WNL
Psychiatric Hx / None
Social Hx / Lives with parents; father is in the military and is currently away; mother is stay at home mom
Alternative/ Complementary Medicine Hx / None shared
Medication allergies: / None / Reaction:
Food/other allergies: / Strawberries / Reaction: / rash
3. Current medications / Drug / Dose / Route / Frequency
Acetaminophen / 220mg / PO / Q4-6h PRN for pain
4. Laboratory, Diagnostic Study Results
Na: / K: / Cl: / HCO3: / BUN: / Cr:
Ca: / Mg: / Phos: / Glucose: / HgA1C:
Hgb: / Hct: / Plt: / WBC: / ABO Blood Type:
PT: / PTT: / INR: / Troponin: / BNP:
ABG-pH: / paO2: / paCO2: / HCO3/BE: / SaO2:
VDRL: / GBS: / Herpes: / HIV: / X-ray: / EKG:
E. Baseline Simulator/Standardized Patient State – Patient B
(This may vary from the baseline data provided to learners)
1. Initial physical appearance
Gender: Male / Attire: Street clothes, pull-ups on under pants
Alterations in appearance (moulage): abrasion to forehead
X / ID band present, accurate / ID band present, inaccurate / ID band absent or not applicable
X / Allergy band present, accurate / Allergy band inaccurate / Allergy band absent or N/A
2. Initial Vital Signs Monitor display in simulation action room: Patient B
No monitor display / X / Monitor on, but no data displayed
Display VS when learner takes them / Monitor on, standard display
BP: 100/66 / HR: 105 / RR: 28 / T: 37.2 / SpO²: 98% r/a
CVP: / PAS: / PAD: / PCWP: / CO:
AIRWAY: / ETC0²: / FHR:
Lungs:
Sounds/mechanics / Left: clear / Right: clear