Scenario title. We re Coming Down Intrahospital Transfer post MET. Designed for (specific group) ICU MET team. Scenario Design team.

Transcription

1 Scenario title We re Coming Down Intrahospital Transfer post MET Designed for (specific group) ICU MET team Scenario Design team Name Maurice Le Guen Cameron Knott Organisation Austin Hospital Date of creation 13/03/2016 1

2 Table of Contents Simulation Proforma... Error! Bookmark not defined. Overall Goals... 3 Learning Objectives:... 3 Faculty Requirement:... 3 Participants... 4 Details for Facilitators... 4 Summary... 4 Simulation Equipment Requirement... 4 Medical Equipment Requirement... 4 Patient Demographics... 6 Scenario Specific Details... 6 Set up overview... 7 Available blood results... 7 Timeline Overview... 7 Key Debrief Points (expected)... 9 Key message slides / handouts... 9 Supportive Educational Material... Error! Bookmark not defined. References

3 Overall Goals To provide real time inter-professional training in the management of an intubated patient on the ward For MET team to develop their understanding of preparation for transfer from the ward For MET team to develop their approach to clinical management of a patient during transfer Learning Objectives: No. Learning Objective 1 Patient preparation for safe transfer using CICM guidelines 2 Communication with ICU, Home Team, Other teams for transfer 3 Clinical management of patient during transfer 4 5 Faculty Requirement: Role Facilitator Manikin Operator Observer Required (tick if yes) Notes Other Nurse faculty member Confederate 3

4 Participants Role Notes 1 ICU MET Doctor Senior help available only over the phone 2 Bed Side nurse 3 ICU MET nurse 4 Details for Facilitators Summary 42 y.o female with exacerbation of asthma. Intubated on the ward and now needs to be transferred to ICU Note: this can either be run as a stand alone SIM or can follow directly after the debrief for the Preparation for Ward Intubation SIM Simulation Equipment Requirement specific manikin is given for reference purposes only Simulator Adult mannikin Gas Supply AV Equipment Miscellaneous Medical Equipment Requirement (Equipment required to optimise fidelity of simulation) ( available, on manikin / actor) Airway, C-Spine & Respiratory 4

5 Hard Collar Blocks/towels Tape Oxygen Supply CPAP O 2 Reservoir Facemask Intubated Nasal Cannula Head-box Suction Yankuer Suction Catheter Self-inflating Bag Ayers T piece Nasopharyngeal airway Oropharyngeal Airway LMA Trachy Kit Intubation Equipment: Humidified Oxygen Fiberoptic Laryngoscope Laryngoscopes (2) ETT Sizes.. Bougies T piece / circuit Filter Stethoscope ET CO 2 detection tape ETT position length at 22 Ventilator itime sec 1.5 Insp O Rate 16 PIP 40 PEEP 10 Other Oxygen Sats Monitor Nebuliser Chest Drain Cardiovascular ECG leads BP cuff Art line CVP Picc Line Cannulas 24G Cannulas 22G Cannulas 20-16G Intraosseous kit Urinary catheter Hickman Line Other Neurological Blood glucose stick Pen Torch Bleeding nares / ears Ant fontanelle bulge Other Abdominal AXR USS Wound Other Exposure / Miscellaneous Rash Limb injury Thermometer O Negative Blood 5

6 Other Paperwork FBC result U&Es result Blood Gas results Copy of CXR Copy of AXR Copy of CT Scan Copy of USS BNF TEG Crashcall.net sheet Em Dept sheet Drug Chart Other Patient Demographics Details Age 42 Weight 100 Sex Female Other relevant Scenario Specific Details Initial Handover given to candidates S admitted to resp ward from ED with exacerbation of asthma. Patient is now intubated (by anaesthetic team who have now left) B Normally well. Known Asthma. Previous ICU admission for asthma A Intubated. On oxylog: RR16; Ti: 1.5 sec. PEEP 10; Vt 700. Borderline hemodynamics. R 6

7 Set up overview Available blood results: Stage 1 ABG in ED. (CXR available?) Stage 2 Stage 3 Timeline Overview Initial settings A B C D Intubated RR 16. Sats 95%. Hr 125. BP 95/56 Sedated. Patient is immediately post intubation. And Anaesthetics have just handed over saying that she was a grade Ib intubation. But they now need to rush off to emergency theatre list. The following elements are missing for the patient to be safely transferred to ICU: E Need to readjust vent settings to become appropriate for asthma. End tidal CO2 no longer connected (left on bvm setup). NIBP is not cycling anymore. The reading on the screen is from 3+minutes ago. Transport suction not set up No infusions or on-going sedation is ready (except for remaining propofol from intubation) ICU is not ready to accept the patient and NUM has not yet been informed of patient being intbuated Stage 1: Initial Assessment & Management Initial Settings Expected Actions A B C Intubated RR 16. Sats 95%. HR 125. BP 88/48 Systematically assesses and manages patient for transport: Airway: ET CO2 attached Ventilator: increases expiration time. Decreases tidal volume. (Decreases PEEP; Decreases RR to account for prolonged expiration) NIBP cycling Stage 1 7

8 D E Sedated. Transport suction setup Prompting Required Stage 2: Have we got all our monitoring attached? If at any stage learner starts to suggest they should attempt transfer and these issues have not been addressed, patient will deteriorate. If they attempt to begin transfer patient will deteriorate suddenly A B Intubated RR 12. Sats 95%. C HR 125. D E Sedated. Expected Actions Learner ensures adequate IV access (at least 2 20g cannula or better) Organises drugs for transfer: o Propofol (2 x 20ml Syringes or infusion set up) o Considers fentanyl or morphine (does not need to be running) o o Metaraminol (infusion or bolus) Neuromuscular blocking drug: any agent of choice to be available (but not necessarily drawn up) o IV fluid bolus or infusion line o NSaline flushes Phone call to ICU senior and or ICU NUM: o Provides update to patient status (i.e. now intubated and latest vital signs) o Discusses need for patient bed in the ICU: ventilated bed needs to be arranged Prompting Required ICU Senior &/or NUM on phone: informs them it will be 10 mins before bed is ready. Do we need a PSA? Stage 2 Stage 3: Expected Actions A B Intubated RR 12. Sats 95%. Ongoing wheeze Ensure infusions setup: o Propofol o Possibly analgesia o IV fluid line and for boluses of medications Considers ongoing management of asthma o Neb or mdi via ETT Stage 3 8

9 C HR 125. D Sedated. E o Mg; adrenaline etc can all options END Prompting Required When did we last listen to her chest? Do we need to get things ready if there s a delay? If at any stage learner starts to suggest they should attempt transfer and these issues have not been addressed, patient will deteriorate. If they attempt to begin transfer patient will deteriorate suddenly Key Debrief Points (expected) No Points 1 Step-wise approach to transfer of patient 2 Consideration as to limited resource environment of transfers 3 Adequate and repeated communication with ICU NUM/Senior/ Other teams as to patient transfer. 4 Consideration as to updating family of transfer to ICU 5 Key message slides / handouts 1) see Teaching Points doc 2) 3) 4) 9

10 References Simulation Proforma: adopted from North West Simulation Education Network, UK Guidelines for the transport of the Critically Ill Adult 3 rd Edition Intensive Care Society 10