Title: “Red in the Face” Interprofessional Simulation Case Scenario
Target Audience: Medical students, medical residents PGY1,RN students, new RN orientees
Learning Objectives for Provider Learners:
- Identify the appropriate vancomycin infusion rate for an adult patient
- Identify the potential complications related to rapid vancomycin infusion
- Recognize signs and symptoms of red man syndrome/allergic reaction
- Prioritize treatments and interventions for red man syndrome
- Collaborate with the interdisciplinary healthcare team using SBAR communication and crisis resource management principles.
Learning Objectives for RN Learners:
- Identify the appropriate vancomycin infusion rate for an adult patient
- Identify the potential complications related to rapid vancomycin infusion
- Recognize signs and symptoms of red man syndrome/allergic reaction
- Prioritize treatments and interventions for red man syndrome
- Implement treatments and interventions for red man syndrome
- Collaborate with the interdisciplinary healthcare team using SBAR communication and crisis resource management principles.
Learner Preparation:
Prior to the simulation session, learners are encouraged to review the incidence and prevalence of MRSA, the treatments of HA-MRSA and CA-MRSA, the common side effects/adverse effects of treatment for MRSA, signs and symptoms of red man syndrome, treatment modalities for red man syndrome, and how to use SBAR and closed loop communication among healthcare team members.
Faculty Preparation:
The faculty should be familiar with the scenario branch points. The physiologic parameters on the patient simulator need to be changed by the faculty or simulation staff in response to the learners’ actions. The faculty should be prepared to discuss red man syndrome as one of the potential adverse effects of rapid vancomycin intravenous administration; differential diagnosis, the etiology, signs and symptoms of red man syndrome; appropriate treatment modalities for this adverse effect, differences between red man syndrome and anaphylaxis, as well as using SBAR and closed loop communication among interdisciplinary healthcare team members.
Since this scenario is designed for interprofessional learners, faculty from each discipline should be present at the scenario as well as the debriefing.
Learner Orientation to Manikin and Environment:
The learners should be oriented to the manikin and vital signs monitor, as well as the room environment. The introduction should include:
- How to obtain vital signs on the manikin
- Breath sounds are normally present and can be auscultated
- Heart sounds are normally present and can be auscultated
- Pulses can be palpated and pulse quality may change if the patient becomes hypotensive
- Bowel sounds are normally present and can be auscultated
- Sweating can be present
- Where to obtain basic hospital supplies: gloves, hand sanitizer, isolation gowns, water pitcher, cups, etc.
- Location of the telephone
- Phone number of the provider following the patient’s case
- Location of the medication cart
- Location of the electronic health record
- How to access and/or enter orders on the electronic health record
Roles/Actors:
The roles in this simulation case scenario are designed to maximize versatility for use in different disciplines and different levels of learners.
RN learner role: / Can be new RN orientee or RN student. Can also be acted by faculty or simulation staff.Provider learner role: / Can be resident/medical student. Can also be acted by faculty or simulation staff.
RN outgoing shift: / Faculty/simulation staff can act in this role
Scenario Background for Learners:
HPI: / Rob Paulson, a 68 year old male, was admitted to the med/surg unit last night for MRSA infection of a previously lanced leg wound. IV vancomycin has been ordered by the admitting care provider.PMHx: / MRSA on leg, diabetes, COPD
PSHx:
Weight: / Tonsillectomy, arm fracture, leg wound I&D
75 kg
Meds: / Doxycycline 7 days po for CA-MRSA prescribed by PMD
Insulin (Novolog)
Proventil (bronchodilator)
Flovent (inhaled steroid)
Allergies: / NKDA
Alcohol/drugs/tobacco: / Denies
Social Hx: / Retired, lives alone
Scenario Background and Instructor Notes for Faculty
An actor will play the role the outgoing shift nurse, who is in a hurry to leave the hospital at change of shift to pick up his/her child from school. The nurse initiates the first dose of vancomycin, but in his/her hurry, neglects to infuse the vancomycin via IV pump at a slow rate. Instead, the vancomycin infusion goes in rapidly by gravity, causing red man syndrome in the patient. The learners will need to identify that the rate of vancomycin infusion is too rapid, identify the reaction, communicate effectively amongst the healthcare team, prescribe the appropriate treatments, and implement the appropriate orders.
Optimal Management Pathway
The RN learner will need to:
- Identify that the medication is not on an IV pump and it should be
- Identify the vancomycin infusion rate as too rapid
- Stop the infusion
- Recognize patient condition is changing
- Assess and examine patient
- Communicate effectively with the learner or actor in the provider role
- Communicate interventions with the patient
- Implement provider orders
The provider learner will need to:
- Examine patient
- Diagnose red man syndrome
- Confirm the vancomycin infusion has been stopped
- Order O2 at 2L/min via NC, order PO H1 and H2 receptor antagonists (diphenhydramine 1mg/kg PO, cimetidine 4mg/kg PO)
- Provide orders verbally or enters orders in the electronic health record or other record
- Communicate effectively with the learners in the RN role
- Communicate plan of care with the patient
- Advises patient of reaction
If the learner(s) manage the patient via the optimal pathway, the vital signs and patient status will return to baseline after the treatments are implemented.
Potential Complication Pathways
If the learner(s) do not follow the optimal management pathway, patient status will continue to deteriorate (See pages 4-6). In that case, the faculty may stop the scenario early and move on to debriefing.
Equipment:
SimMan 3G - In this particular scenario, the manikin has been modified to simulate the face/neck/upper torso skin flushing or erythematous rash of red man syndrome by placing red LEDs under the manikin’s skin. The LEDs, connected to a switch, should be turned on by a faculty or simulation staff on cue. The case cannot use a pre-moulaged manikin as the development of the skin flushing is not present on the team’s arrival.
Contact Isolation” sign – place on door to patient room
IV Fluid – NS
IV Medications –Vancomycin 1 gram in 250 mL NS hanging
PO Medications –Diphenhydramine, cimetidine
ID bracelet
Phone
Gloves
Hand Sanitizer
Diaphoresis
Nasal Cannula
Non-rebreather
Isolation gowns
Patient Chart
Admission Sheet
MAR
Physician Order Sheet
1
Time / Manikin Settings and Changes / Desired Learner Actions / Actor Cues / Prompts / Teaching Points0-3 min / VS now :
BP: 130/89
RR: 16
HR: 84
Pulse Ox: 95%
LOC:A&O x 3, calm, communicative
Physical Status
Lungs: normal
BS: positive x4
Operator Verbal Sounds:
I’m okay, my thigh hurts where they drained that thing. / RN Learner:
- Gown and gloves prior to entering patient room
- Identifies patient and self
- Assesses LOC
- Obtains vital signs
- Obtains history
- Checks medication and rate
- Recognizes vancomycin infusion rate as too rapid
- Stops vancomycin infusion
- Tells RN learner: “I have to go pick up my kid from school. I just started the antibiotic, he’s stable, will you just double check everything for me?”
- Intentional error: allows vancomycin to infuse rapidly via gravity
- Leaves room in a hurry before RN learner can ask any questions or assess patient
- Importance of maintaining contact isolation.
- Importance of appropriate handoff procedure
- Appropriate Vancomycin infusion rate: infuse over 2-4 hours
3-10 min / VS change: CHANGE VS FIRST, THEN VERBAL REACTION (agitation, SOB)
Sweating, switch on LEDs
BP: 110/65
RR: 22
HR: 135
Pulse Ox: 92%
LOC:A&O x 3
Operator Verbal Sounds:
Becomes agitated and increasingly anxious
VS changes:
See page 6 for VS changes in response to learner actions / RN Learner:
- Recognizes patient condition is changing
- Contacts Provider Learner via telephone
- Communicates patient status to provider using SBAR
- Gowns and gloves prior to entering patient room
- Identifies self
- Examines patient
- Diagnose red man syndrome
- Communicates diagnosis and orders with RN learner using SBAR
- Orders:
Diphenhydramine75 mg PO
Cimetidine 300 mg PO
- Enters orders in the electronic health record
- Discusses diagnosis and plan of care with patient
- Acknowledges orders using closed loop communication
- Administers:
Diphenhydramine 75 mg PO
Cimetidine 300 mg PO
- Continues talking to patient
- Reassesses patient
- Communicates patient status and implementation of orders with Provider Learner using closed loop communication
Orders:
- Diphenhydramine75 mg PO
- Cimetidine 300 mg PO
- O2 at 2L/ min via NC
- Enters orders in electronic health record
- Differential diagnoses
- Signs and symptoms of red man syndrome
- Etiology of red man syndrome
- Treatment modalities for red man syndrome
- Differences between red man syndrome and anaphylaxis
- Importance of using SBAR and closed loop communication
- Example of SBAR:
- S: Mr. Paulson, a patient here in room 1434 is in acute distress, he’s agitated, O2 saturation dropped to 92%, heart rate increased to 135, and developed an erythematous rash on his face.
- B: He is a 68 year old male admitted last night for MRSA infection of a leg wound. He just received IV vancomycin.
- A: I noticed that the vancomycin was infusing rapidly when he developed the symptoms. I stopped the vancomycin infusion.
- R: I would like for you to come assess him as soon as possible. When can you get here?
1
1
RN Learner Critical Actions ChecklistCompeting Team______
Red in the Face
Critical Actions / Criteria / Score1 / Sanitizes hands / Does NOT wash hands / 0
Some members wash hands / 1
All team members wash hands / 2
2 / Infection Control / Does NOT gown and glove before approaching patient / 0
Some members gown and glove before approaching patient (if more than 1 RN learner) / 1
Gowns and gloves before approaching patient / 2
3 / Introduce Self/Team / Does NOT introduce self/team / 0
Introduces self/team / 2
Vital Signs/Physical Assessment
4 / Obtains vital signs / Does NOT obtain vital signs / 0
Obtains vital signs partially or inaccurately / 1
Obtains vital signs completely and accurately:
Systolic BP 125-135
Diastolic BP 85-95
HR 80-90
RR 14-18
SpO2 95% / 2
5 / Assesses Lung sounds / Does NOT auscultate lungs / 0
Auscultates anterior lung sounds / 1
Auscultates anterior and posterior lung sounds / 2
6 / Assesses Wound / Does NOT assess wound verbally or physically / 0
Assess wound verbally or physically / 2
7 / Checks Vancomycin infusion rate / Does NOT identify incorrect rate / 0
Identifies incorrect rate / 2
8 / Stops Vancomycin infusion / Does NOT stop vancomycin infusion when patient condition changes / 0
Stops vancomycin infusion when condition changes / 2
9 / Reassesses and recognizes changes / Does NOT recognize change / 0
Recognizes changes when patient speaks / 1
Recognizes changes in physiologic condition / 2
Communication and Teamwork
10 / Team Leader / Does not identify team leader verbally / 0
Identifies team leader verbally / 2
11 / Team Member Roles / Does NOT maintain clearly defined team member roles / 0
Maintains clearly defined team member roles / 2
12 / Uses closed-loop communication among healthcare team: 1st team member call out request/action; 2nd team member checkback request/action, then 2nd team member confirm request fulfilled/action performed. / Does NOT use closed-loop communication / 0
Uses closed-loop communication some of the time / 1
Uses closed-loop communication all the time / 2
13 / Contacts provider / Does NOT contact provider / 0
Contacts provider / 2
14 / Uses SBAR: Situation / Does NOT communicate Situation to provider / 0
Communicates Situation to provider partially / 1
Communicates Situation to provider completely and
accurately / 2
15 / Uses SBAR: Background / Does NOT communicate Background to provider / 0
Communicates Background to provider partially / 1
Communicates Background to provider completely and
accurately / 2
16 / Uses SBAR: Assessment / Does NOT communicate Assessment to provider / 0
Communicates Assessment to provider partially / 1
Communicates Assessment to provider completely and
accurately / 2
17 / Uses SBAR: Recommendations / Does NOT communicate Recommendations to provider / 0
Communicates Recommendations Situation to provider
partially / 1
Communicates Recommendations Situation to provider
completely and accurately / 2
18 / Discusses Interventions with Patient / Does NOT discuss interventions with patient / 0
Discusses interventions with patient partially / 1
Discusses interventions with patient / 2
Implementing orders/interventions
19 / Administers Benadryl / Does NOT administer diphenhydramine / 0
Administers diphenhydramine incorrectly / 1
Administers diphenhydramine correctly / 2
20 / Administers Zantac / Does NOT administer cimetidine correctly / 0
Administers cimetidineincorrectly / 1
Administers cimetidine correctly / 2
21 / Re-assesses patient and vital signs throughout simulation / Does NOT re-assess patient and vital signs / 0
Re-assess patient some of the time / 1
Re-assesses patient and vital signs continually / 2
22 / Administers Oxygen / Does NOT administer oxygen correctly / 0
Administers oxygen correctly / 2
Highest possible score = 44 / Total Score:
Provider Learner Critical Actions Checklist Competing Team______
Red in the Face
Critical Actions / Criteria / Score1 / Sanitizes hands / Does NOT wash/sanitize hands / 0
Some members wash/sanitize hands / 1
All team members wash/sanitize hands / 2
2 / Infection Control / Does NOT gown and glove before approaching patient / 0
Some members gown and glove before approaching patient (if more than 1 provider learner) / 1
Gowns and gloves before approaching patient / 2
3 / Introduce Self/Team / Does NOT introduce self/team / 0
Introduces self/team / 2
Reviews History/Physical Assessment
4 / Review History/Vital Signs / Does NOT review history and vital signs / 0
Reviews history or vital signs but not both / 1
Reviews history and vital signs / 2
5 / Assesses Lung sounds / Does NOT auscultate lungs / 0
Auscultates anterior lung sounds / 1
Auscultates anterior and posterior lung sounds / 2
6 / Assesses Wound / Does NOT assess wound verbally or physically / 0
Assess wound verbally or physically / 2
Communication and Teamwork
7 / Team Leader / Does not identify team leader verbally / 0
Identifies team leader verbally / 2
8 / Team Member Roles / Does NOT maintain clearly defined team member roles / 0
Maintains clearly defined team member roles / 2
9 / Uses Closed-Loop Communication Among Healthcare Team: 1st team member call out request/action; 2nd team member checkback request/action, then 2nd team member confirm request fulfillment/action performed. / Does NOT use closed-loop communication / 0
Uses closed-loop communication some of the time / 1
Uses closed-loop communication all the time / 2
10 / Uses SBAR: Situation / Does NOT communicate Situation to RN learner / 0
Communicates Situation to RN learner partially / 1
Communicates Situation to RN learner completely and
accurately / 2
11 / Uses SBAR: Background / Does NOT communicate Background to RN learner / 0
Communicates Background to RN learner partially / 1
Communicates Background to RN learner completely andaccurately / 2
12 / Uses SBAR: Assessment / Does NOT communicate Assessment to RN learner / 0
Communicates Assessment to RN learner partially / 1
Communicates Assessment to RN learner completely and accurately / 2
13 / Uses SBAR: Recommendations / Does NOT communicate Recommendations to RN learner / 0
Communicates Recommendations Situation to RN learner partially / 1
Communicates Recommendations Situation to RN learner completely and accurately / 2
14 / Communicates with Patient / Does NOT discuss diagnosis and plan of care with patient / 0
Discusses diagnosis or plan of care with patient, but not both / 1
Discusses diagnosis and plan of care with patient / 2
Provider Learner: Diagnosis/Orders
15 / Diagnose Red Man Syndrome / Does NOT diagnose Red Man Syndrome / 0
Diagnose Red Man Syndrome / 2
16 / Diagnose Red Man Syndrome / Does NOT confirm vancomycin infusion is stopped / 0
Confirms vancomycin infusion is stopped / 2
17 / Orders Treatment / Does NOT give any orders to RN learner / 0
Orders some but not all of the following: oxygen, diphenhydramine 75mg PO, cimetidine 300mg PO / 1
Orders Oxygen, diphenhydramine 75mg PO, and cimetidine 300mg PO / 2
18 / Enters Orders in Electronic Health Record / Does NOT enter orders in electronic health record / 0
Enters some but not all orders in electronic health record / 1
Enters all orders in electronic health record / 2
Highest possible score = 34 / Total Score:
1
Debriefing Plan:
- In groups, with video and independent peer observers
- Debriefing Materials
- How did it feel?
- What do you think went well?
- What did you have difficulty with?
- Is there anything you would have changed/done differently?
- Rules
- Safe learning environment -communicate to learners that: they should maintain respect for each other, their questions and concerns will be acknowledged, they will receive honest feedback without being judged
- Confidentiality
- Non-punitive
- Questions to Facilitate the Debriefing
- What antibiotic was the patient receiving?
- What should the provider observe for when administering vancomycin?
- What types of hypersensitivities can occur when administering vancomycin?
- What was this patient experiencing?
- When does red man syndrome typically occur?
- Under what conditions does red man syndrome occur?
- How can the incidence of red man syndrome be prevented?
- If red man syndrome occurs what is the most important intervention?
- If red man syndrome occurs what is a pharmacologic intervention?
- How long should vancomycin be administered over?
- Can vancomycin be administered after a patient experiences red man syndrome?
- Answers to Debriefing Questions
- Vancomycin
- Hypersensitivities or allergies
- Red man syndrome and anaphylaxis (hypersensitivities)
- Red man syndrome
- Within 4-10 minutes of beginning the antibiotic infusion or soon after the completion
- When vancomycin is infused over too short a period of time, less than 60 minutes
- Slower infusion rate (greater than 60 min) or pretreatment with H1 and H2 receptor blockers (diphenhydramine, cimetidine)
- Stopping the infusion
- H1 and H2 receptor blocker(diphenhydramine, cimetidine)
- 1 gram over at least 90 minutes or longer
- Yes. Vancomycin is much better tolerated when it is given in smaller and more frequent doses. In clinical situations where prolonged infusion times are often impractical, as in the intensive care unit or an operative setting, especially ambulatory orthopedic or emergency procedures, pretreatment with antihistamines combined with an H2 receptor blocker can offer protection against this infusion-related reaction. (Sivagnanam et al., 2003)
Pilot Testing: