Facilitator s Manual to the Delirium Trigger Videos

Transcription

1 Facilitator s Manual to the Delirium Trigger Videos November 2005

2 Facilitator s Manual to the Delirium Trigger Videos Table of Contents DESCRIPTION OF THE VIDEOS... 3 LEARNING OBJECTIVES... 3 INTENDED AUDIENCE... 3 PREREQUISITES... 4 INSTRUCTOR QUALIFICATIONS... 4 MATERIALS PREPARATION... 4 REQUIRED RESOURCES... 4 PROCEDURES FOR IMPLEMENTATION... 6 INDIVIDUAL VIDEOS... 7 ASSESSMENT AND EVALUATION CITATION COPYRIGHT INFORMATION REFERENCES FEEDBACK FORM Page 2 of 14

3 Description of the Videos Trigger videos are short pieces of film (1-5 minutes long), generally only a few minutes long whose aim is to stimulate and provoke learning. The use of video in medical education is now common place. The trigger film has been found to be an excellent stimulus for discussion and particularly effective for analysis of complex issues in health care. Use of trigger videos can enhance medical education programs by encouraging an active learning process, in which learners can identify with the situations and problems posed in the video, and are motivated to seek an action-oriented solution to those situations which exist in health care. Such an approach empowers learners to develop their own answers in a supportive and mutually reinforcing context. Reinforce an important point or skill with trigger videos. These are one to two minute video clips produced by GeriU. The videos contain a visual scenario regarding delirium that the learners must address. There is often an emotional appeal to the video. Ask students, working in small groups, to view the situation, identify the problem, identify different courses of action, and then make recommendations. These videos deliver the information in an interactive way, step-by-step, through written text, animations, graphics and video clip demonstrations. These videos were originally created August 2005 by GeriU, the Online Geriatrics University, at the Stein Gerontological Institute. Expertise was provided by faculty members from the University of Miami - Miller School of Medicine, and the Miami VA, including Drs. Miguel Paniagua, Axel Juan and J. Ruiz. Learning Objectives Appreciate that delirium is a serious medical/surgical problem Recognize potential risk factors for developing delirium In a given patient, recognize characteristic findings of delirium Intended Audience Medical students Internal Medicine and Family Medicine residents Anesthesia residents Geriatrics fellows Nurses Page 3 of 14

4 Prerequisites Knowledge of the DSM IV diagnostic criteria for delirium. Instructor qualifications Basic small-group facilitation skills Basic teaching with video skills Materials Preparation Before the Session: laptop or personal computer (IBM or Macintosh) with speakers and QuickTime software, CD containing digitized videos. During the Session: Distribute participant s manual Required Resources System Requirements (viewing on web) Apple QuickTime Windows OS: Internet Explorer 6.0 and above, Netscape Navigator 7.0 and above Macintosh OS: Mozilla 1.0 and above (which uses the same engine as Netscape) Playing the videos Some videos and animations on this web site use QuickTime. QuickTime is a plug-in for your web browser that allows you to view video over the internet. To view those videos and animations, you must have QuickTime installed on your computer and set up to work with your web browser. You can go to the QuickTime page on Apple's web site You can download the version of QuickTime that will work on your computer from that page. Follow the directions provided by Apple. Watching video clips on your computer requires a 3- step process. You must Download, Install, then Run a video clip viewer called QuickTime. See the installing instructions first. When you start QuickTime, it is loaded first and a screen pops up with the QuickTime logo. Since you have already downloaded the current version, click on the Later button. Page 4 of 14

5 Usually, QuickTime movies are set up to begin playing automatically and some of the controls shown below are not displayed. At other times, you will see the controls shown below. There may be a delay while the interconnection with the online files creates a buffer file. The rest of the controls are the same as those used on most music and video playback equipment such as video tape recorders and CD players. QuickTime Video Controls To view the video clip, click on the play button in the middle of the player controls. Press the single arrow buttons to go to the beginning or end of the video clip Use the double arrow buttons to move backwards or forwards through the QuickTime video clip Use slide tracking bar to manually slide to any time within the QuickTime file. Use the slider to control the level of volume. Page 5 of 14

6 Procedures for implementation Suggested agenda for a 90-minute session Introductions (5 minutes) Review learning objectives and provide an overview of the session Ask students to give examples of situations in which the assessment and management of delirium might be neglected Ask students to give examples of strategies to overcome the problems they reported Videos Clinical Vignettes First round (10 minutes) Play the first group of video clips. Videos Clinical Vignettes - Preparation in pairs (10 minutes) Give each pair students 1 (ONE) sheet with the questions that pertain to the first group of video clips. Give the students a few minutes to review the material. Explain to them that they should attempt to answer the questions attached to them. They will be asked to turn in their worksheets with their answers and the comments by others at the end of the session. First Group Discussion (20 minutes) Review common manifestations of delirium and its predisposing conditions Circulate the Confusion Assessment Method (CAM) and the DSM criteria for delirium Ask students to give examples of reasons why individuals with delirium may not be appropriately assessed and managed Divide the group in groups of 3 or 4 Videos Clinical Vignettes Second round (10 minutes) Play the second group of video clips. Videos Clinical Vignettes - Preparation in pairs (10 minutes) Give each pair students 1 (ONE) sheet with the questions that pertain to the second group of video clips. Give the students a few minutes to review the material. Explain to them that they should attempt to answer the questions attached to them. They will be asked to turn in their worksheets with their answers and the comments by others at the end of the session. Second Group Discussion (15 minutes) Taking turns, a representative from each pair will read out loud to the rest of the group their answer to the questions related to the second group of video clips After each answer, the other students will comment on the answers suggested Ask students to give examples of manifestations of delirium Explain the common complications of delirium Ask the students to propose strategies to improve the recognition of delirium Overall Discussion/Debriefing (10 minutes) Discuss how to apply the Confusion Assessment Method Review learning objectives and ask students to identify the main take away message Page 6 of 14

7 Individual Videos Description: This video shows a patient who is not improving despite the use of an antipsychotic medication. Pharmacotherapy is not the ideal first-line treatment in delirium. The physician should have examined the patient and reviewed medications and laboratory tests before administering more haloperidol. Video DEL001: Give him Haldol Duration: 12 seconds What could be causing delirium in this patient? How could the physician have managed this situation differently? Description: This video demonstrates how patients with delirium have abnormal perception. They may mistake sounds and images in the environment for something else (illusionary). They may also have hallucinations. How could these physicians approach the patient? Video DEL002: Wrong patient Duration: 27 seconds Description: This video demonstrates how delirium can occur in the absence of other obvious findings on physical examination. In this case the physician fails to recognize a potentially serious situation because he only pays attention to the standard vital signs and the appearance of the wound. Besides not recognizing the abnormal behavior of the patient, the physician also failed to communicate well with the wife, thereby missing another opportunity to identify the problem though a collateral information source. Video DEL003: He s doing great! Duration: 1 minute, 20 seconds What could be causing delirium in this patient? Page 7 of 14

8 Description: This video demonstrates delirium as a consequence of an infection, pneumonia. Although it is a reversible condition, delirium is often misdiagnosed as dementia. Consequently, patients with good rehabilitation potential are denied the chance to undergo treatments that might help them recover from their illness, and regain their functional independence. This patient exhibits disorientation and disorganized thought. Video DEL004: He s just senile Duration: 36 seconds Description: This video demonstrates how behavior can fluctuate in delirium, from extreme somnolence and sometimes coma, to agitation that resembles mania. This patient has disorganized thought, fluctuating abnormalities in level of consciousness throughout the day, and psychomotor agitation. Video DEL005: Sleeping like a baby Duration: 1 minute, 7 seconds How could the physician have managed this situation differently? Video DEL006 : A strange tongue Duration : 1 minute, 17 seconds Description: This video demonstrates an important feature of delirium, reversibility. Two months later the patient had recovered completely. It may take longer than that in some cases, but delirium usually improves soon after the offending factors are addressed. Patients can be made more confused by the environment, and in this case a foreign language being spoken. It is very hard to tell whether patients have some sensory capacity present, even when they seem to be in coma. The safest practice is to avoid inappropriate conversations near, and unnecessary stimulation of the patient altogether. Memory impairment is also demonstrated by this video. Page 8 of 14

9 Description: This video demonstrates how distressing delirium can be to family members and relatives. The patient's restlessness can make it difficult to administer essential treatments. For example, the patients tug at invasive devices such as intravenous lines or catheters. It is possible that this patient is confused because of an often missed cause of delirium, alcohol withdrawal. Video DEL007: Drinking buddy Duration: 41 seconds What would be the next step in his evaluation and management? Description: This video demonstrates that patients who have pre-existing cognitive deficits and risk factors for delirium should be treated with extra precautions to prevent delirium in the post-operative setting. Recognition of pre-existing cognitive problems is better done with the MMSE or MiniCog than with simple questions about orientation to self and place. Video DEL008: The pre-op clinic What are the risk factors for delirium that can be seen in this Duration: 1 minute, 30 seconds Description: This video demonstrates the importance of communicating with family members, friends or other caregivers in order to obtain collateral information about the fluctuation in mental status. Hearing impairment (sensory deprivation) is a risk factor for delirium. The features illustrated here include disorganized thinking, altered sleep-wake cycle, altered level of consciousness and inattention. Video DEL009: Post-op rounds Duration: 53 seconds Page 9 of 14

10 Table of features that may be triggered by each video Video Delirium is often missed Delirium is often caused by a serious underlying problem Delirium is an acute problem Delirium fluctuates Inattention is an important characteristic of delirium Delirium often courses with thought disorganization Delirium often results in altered level of consciousness In some cases, hyperalertness is the predominant feature In some cases, somnolence is the predominant feature Infections are a common cause of delirium Medications are a common cause of delirium Pre-existing cognitive and sensory deficits are risk factors for delirium Assessment and evaluation Students complete session evaluations Faculty complete student and session evaluation Rate each student s contributions to the small group session on a five-point scale (1= poor to 5=excellent). In your ratings, you can take into consideration their participation in the group process both in terms of amount of participation and whether the student s input hampered or enhanced the group process as well as their participation in the discussion. We have not yet conducted a formal evaluation of this program. Page 10 of 14

11 Citation Ruiz JG, Paniagua M, Milanez M, Juan A, Phancao F, McEntire A, Picardo R. Delirium Trigger Videos (Digital videos). GeriU, the Online Geriatrics University, Stein Gerontological Institute, 2005 Copyright information All materials in this module were produced by the Stein Gerontological Institute. All further reproduction rights are given through written permission only. Page 11 of 14

12 References 1. Ber R, Alroy G. Twenty years of experience using trigger films as a teaching tool. Acad Med. Jun 2001;76(6): Bogardus, S. T., Jr., Desai, M. M., Williams, C. S., Leo-Summers, L., Acampora, D., & Inouye, S. K. (2003). The effects of a targeted multicomponent delirium intervention on postdischarge outcomes for hospitalized older adults. Am J Med, 114(5), Fick, D. M., Agostini, J. V., & Inouye, S. K. (2002). Delirium superimposed on dementia: A systematic review. J Am Geriatr Soc, 50(10), Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med, 340(9), Inouye, S. K. (1998). Delirium in hospitalized older patients. Clin Geriatr Med, 14(4), Nichols J. The trigger film in nurse education. Nurse Educ Today. Aug 1994;14(4): Westberg J, Jason H. Teaching Creatively with Video: Fostering Reflection, Communication and Other Clinical Skills. New York: Springer Publishing Company; Page 12 of 14

13 Feedback Form Please tell us what you think of this training material. Your feedback will help us improve the training materials we develop. Please complete this questionnaire, and fax it to (305) , or mail it to: GeriU Coordinator Stein Gerontological Institute 5200 NE 2 nd Ave Miami, FL Alternately, you may visit and fill out the questionnaire on-line. 1. How was your overall experience with the training material? Excellent Good Fair Inadequate Bad 2. How appropriate was the level of the content? Much too advanced Too advanced At the right level Too basic Much too basic 3. Do you feel the materials were effective at enabling you to meet the learning objectives specified? Very effective Effective Neither effective nor ineffective Ineffective Very ineffective 4. How easy or difficult was it to use the training material? Very easy Easy Neither easy nor difficult Difficult Very difficult 5. Did you have any technical problems when viewing the material on your computer or DVD player? Yes No If Yes, please specify: 6. Please indicate which best describes your use of the material: I am using the material as part of self-directed learning to improve my care providing skills. I am using the material to help teach others better care providing skills. Other (please specify): 7. Do you have any other comments about this training material? Page 13 of 14

14