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Perinatal Clinical Academy_ SCE OB Emergency‐ 1

PHS AND AFFILIATES

SCE: OB Emergency

Perinatal Clinical Academy

Simulated Clinical Experience and Facilitator Guide

Last Revision: July 26, 2016


Bethany Bell Age: 28 Weight: 90 kg

Learner Information The learner is providing care for a 28‐year‐old female who is recovering from spontaneous vaginal delivery after Pitocin induction (for postdates) 4 hours ago. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 wks gestation. She was transferred from L&D to Postpartum 4 hours postpartum after an uneventful recovery. Baby has breastfed successfully twice for 30 minutes each time. Bethany is ready for her second hourly assessment and fundal check.

Facilitator Information

Learners are expected to perform the appropriate postpartum assessments on both mother and baby and recognize increased bleeding related to an over distended bladder. The patient becomes hypotensive and tachycardic. Learner expected to continue fundal massage despite requests from patient to stop, call for additional nursing support, weigh and save pads, manage the patient’s pain and notify the provider about the change in condition. Learners are expected to carry out LIP orders, as appropriate, in a timely manner. Learner should also provide emotional and educational support to patient and family regarding hemorrhage event. The scenario ends after completion of handoff report.


Pre SIM Preparation Required

Patient: Bethany Bell Age: 28 Weight: 90 kg

Bell, Baby Boy 2 hours old, 41 1/7 weeks Weight: 4 Kg

You will be providing care a 28‐year‐old female who is 2 hours postpartum from a vaginal delivery. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 weeks gestation.

Assesses and maintains safe and complete care of both mother and baby

Performs Head to Toe physical assessment and focused assessments as indicated

Evaluates the patient’s condition and response to interventions and modifies the nursing care in timely manner

Identifies signs and symptoms of an unstable obstetric patient using a systematic process

Identifies outcomes of interventions ordered and proceeds appropriately

Demonstrates safe and comprehensive administration of fluids and medications

Maintains accurate and precise intake and out take records

Utilizes the Nursing Process

Maintains effective closed loop communication with all members of the health care team

Demonstrates safe and comprehensive medication administration

Provides a culture of safety for all patients

Demonstrates awareness of clinical environment, infection control, aseptic technique, fall prevention, skin care, behavioral health , and pain management

Demonstrates caring and advocacy for patient and family Preparation required: This scenario integrates skills and education from previous simulated and non‐simulated clinical experiences. Please review standards, medications, and didactic education as needed. Suggested medications to review and be prepared to administer:

Oxytocin

Hemabate

Methergine

Misoprostol

Magnesium sulfate

Calcium gluconate

Ephedrine

Terbutaline Suggested Evidence Based Practice (EBP) and institution specific policies for review:

Bleeding Emergency Obstetric Hemorrhage

Epidural Catheter Analgesia / Anesthesia In Obstetrics

Evacuation of Mothers and Babies

Hypertension in Pregnancy

Induction or Augmentation of Labor with Oxytocin

Labor Patient Management

Neonatal Resuscitation

Postpartum Management and Discharge

Preterm Labor (PTL)

Trauma in Pregnancy


SIM Set Up Checklist SCE: OB Emergency

Print patient labels with correct birthdate and MRN, then label patient, labs, orders appropriately.

Standard Room Supplies

Family observer clipboard and SAFETY /QUALITY OBSERVER CHECKLIST

Oxygen regulators x2 with Adult ambu bag hanging and Non rebreather mask on O2 regulator

Suction regulators, canister, suction tubing and yankuar in package sitting on top x2

Adult and Newborn Stethoscopes x4

Bathroom: peri‐care supplies (Pink bucket with Mesh panties, chuks pads x4, large pads x2, small pads x2, peri bottle) and urine hat

Call Bell, thermometer (oral and temporal), flashlight, reflex hammer

Code cart in hallway with first responder box on top

Extra pillows

IV pump

Monitor

Neonatal code cart in hall

Over‐the‐bed table

WOW

For PP/ANTE

Bassinet with bulb suction in bed o Top drawer; neonatal ambu bag, pink basin with bath supplies ( yellow comb, J&J soap,

dry washcloths) diapers and wipes, shirts, blankets

Breast pump and parts

Supplies for OB EMERGENCY Sim

Manikin: Birthing manikin/Adult female and infant

MOTHER: o Patient ID Band and Matching Baby ID band o Postpartum Gown on o Birthing manikin with hemorrhage capabilities o Small pool of blood and light clots inside vagina o Mesh underwear with peripad (moderate red blood on pad at start of

sim) o BP Cuff and sat probe on o IV (18 gauge) in L arm o IV pump on pole o Emesis basin on bedside table

BABY: o Bassinet with blue bulb suction, and crib card o Check that baby has: ID Band, Hugs Tag, hat, t‐shirt, diaper, swaddle

blanket. o Baby in patients arms

Tech Recording equipment ready‐ if available

Manikin specific control software ready to go

Facilitator guide


Medication and Supplies – Place in “med room”

2 bags of Oxytocin (Pitocin) 500 mL

Fentanyl 100 mcg/mL vial

Motrin 600 mg tabs packet

Percocet 5/325 mg tabs packet

OB Hemorrhage med kit (per facility) o Hemobate 250 mcg in ampule o Methergine 200 mcg in vial o misoprostol 200 mcg tabs

OB Hemorrhage cart with supplies

Scale for weighing pads Runner: Supplies to be placed in control room

Facilitator guide ( marked as revision guide)

Handoff/SBAR

Extra blood clots

Foley to be quickly placed in the patient ( not the objective of this sim) Conference Room Flipchart and Markers

Facilitator Guide

Learners Roles and Responsibilities


Pre Brief Introduce yourself

Check in with residents

A little about today… Today’s scenario is meant to use what you’ve learned over the past few weeks

and your critical thinking to decide what interventions are needed for your patients and what

orders/diagnostics you should expect.

A note about realism…Yes we know that an LIP would be making decisions but we want to see how you

think through the patient situation.

What is your process in prioritizing the needs for your patients?

What questions do you ask yourself to make conclusions about your patient?

DO YOU FEEL LIKE YOU KNOW HOW TO RECOGNIZE A PATIENT EMERGENCY?

WHAT SORT OF EMERGENCY ARE YOU CONCERNED ABOUT?

WHAT IS THE MINIMUM YOU NEED TO KNOW TO RESPOND TO AN EMERGENCY?

Example: where to find the code cart, hemorrhage meds, C/S tray, etc…

WHAT IS THE NURSE’S ROLE IN AN EMERGENCY?

Code Blue o Primary Nurse o Responding Nurse

Neonatal Code o Primary Nurse o Responding Nurse

Prolapse Cord o Primary Nurse o Responding Nurse

PPH o Primary Nurse o Responding Nurse

Shoulder Dystocia o Primary Nurse o Responding Nurse

REVIEW OBJECTIVES OF THIS SIM:




Identifies signs and symptoms of postpartum hemorrhage using a systematic process




Maintains accurate and precise intake and out take records

REVIEW THE EXPECTATION OF SIMULATION

When in doubt, “treat it as real”

Operate as a TEAM

Think OUT LOUD

Use SBAR for all communication

Educate the patient and family member

Demonstrate caring and compassion

Demonstrate excellent safety practices o Patient identification o Infection prevention “Gel in Gel out” o Skin management o Pain management o Fall prevention o Medication safety and double checks

Care for yourselves o Wear gloves o Protect your body

ASSIGN ROLES FOR SIMULATION

See Appendix for Roles descriptions

Give reminder about EPIC (signed and held orders, if applicable) and send to learners to break. Please

let support staff know you are on break so they can finish preparation for SIM


Overview Chart of SIM Highlights State 1‐ Initial Assessment

VS: HR 90’s, BP 110s/60s, RR teens, SPO2 97% on room air, Temp 98.6F Baby: HR 148, RR 44, Temp 98.6F, Glucose 45

Learners Facilitator Patient TECH

All entering room should gel hands

1. Introduce self to patient

2. Begin comprehensive post‐vaginal delivery assessment; VS, Pain level, Fundal check

3. Assists patient to bathroom after recognizing distended bladder

4. Reassess fundus/lochia after voiding; educates pt about frequent voiding

5. Newborn assessment and

vitals

6. Documents information

Cues tech to transition to State 2‐Beginning Hemorrhage when assessments is complete.

If patient is not taken to bathroom to void, then transition to State 3‐ Progressing Hemorrhage

Voice of Patient responding to RN’s questions

Tired, but happy about baby

Pain 4/10 with mild cramping, tolerable

When asked about voiding, responds that she does not feel like she has to go, but is willing to try

Fundus firm and deviated to the right

Bleeding‐ turned off, change at facilitator discretion

After voiding: Fundus firm, midline, at umbilicus

Bleeding‐mild, no clots

RUNNER: Respond as Charge RN if called and suggest emptying the bladder (after asking what they think is going on FIRST!)

Call into room as Charge RN after the patient is back from bathroom and reassessed to report that another patient needs them

MD ORDERS: If RN calls about fundus/bleeding; ask when she last voided

As the facilitator and tech of this scenario, please remember to be flexible as far as the flow of the

simulation. Based on the learner’s choices the facilitator may need to change the course of the

simulation. Our goal, as always will be to keep the learners on path to meet the educational

objectives.


(One Hour Later) State 2‐ Beginning Hemorrhage VS: HR 110’s; BP 90s/50s; RR in the 20s, SpO2 96% on RA, Temp 98.6F Baby: Stable and sleeping



1. Assesses VS, fundus and lochia; recognizes changes in condition

2. Initiates fundal massage and calls for additional help

3. Weighs/saves pads

4. Notifies provider about change in condition and for further orders

5. Carries out orders or delegates in a timely manner as appropriate

5. Documents data

Cue tech to transition to State 3‐ Progressing Hemorrhage once orders are completed

If the bleeding is to your satisfaction cue tech to stay in State 2‐ Beginning Hemorrhage. Moving to State 3‐ Progressing Hemorrhage will increase the bleeding

Voice of Patient responding to RN’s questions

Anxious about bleeding and in pain from fundal massage

“I don’t understand why you have to keep pressing on my stomach when it hurts so bad!!”

ANNOUNCE:

1 hour has passed

Fundus boggy Bleeding off, turn on and then back off when instructed by facilitator

RUNNER: Respond as charge RN as needed and let the participants direct you in what they need; ask if they have notified LIP if they have not already

MD ORDERS: (verbal orders) Restart Pitocin at 150 mL/hr Give Methergine 0.2 mg IM x 1 STAT Notify me if bleeding does not improve


State 3 – Progressing Hemorrhage VS: HR in the 110s, BP in high 90s/50s, RR in upper 20s and SpO2 above 95% on O2 (low 90’s if not on O2), Temp 98.6F LOC: Dizzy, light‐headed; still responsive Baby: Stable, sleeping



1. Notes changes in VS, patient’s LOC, fundus/lochia

2. Calls for additional assistance and initiates oxygen delivery based on dropping O2 sats

3. Using ISBAR, notifies provider of continued bleeding and changes in condition, asks for provider to come to bedside


5. Supports patient and family emotionally by providing communication and updates

6. Documents data

Cue tech to transition to State 4‐Slight Improvement with Provider Intervention once LIP is called

Report feeling dizzy, light‐headed with tingling in lips and fingers

Very anxious and concerned about baby

Bleeding off, turn on and then back off when instructed by facilitator

RUNNER: Come into room as a “helper” and place the catheter and 2nd IV (Foley insertion is not a learner objective for this SIM)– Announce that you have drawn the OB Hemorrhage panel during IV start.

MD ORDERS: Place indwelling Foley catheter Place 2nd IV with LR fluid bolus of 1000 mL Asks about total EBL to this point OB Hemorrhage Panel and Type and Cross 2 units PRBCs


State 4 – Slight Improvement with Provider Intervention (Provider Performs a Manual Evacuation) VS: HR in the 120s, BP 90s/50s, RR in the low 20s and SpO2 97% with 2 L O2 via NC, Temp 98.6F LOC: Alert but anxious Baby: Stable, still sleeping


All entering room should gel

hands

1. Assist provider with manual evacuation of clots/products of conception

2. Continue to monitor for changes in condition, increased bleeding

3. Supports patient and family

4. Advocates for patient regarding pain during procedure


6. Documents data

Cue tech to transition to State 5‐ Bleeding Stable and Patient Recovering after clots removed and meds given

Responds to RN’s

questions.

Wants to know she can

have anything else for

the pain when provider

doing manual

evacuation (pain at

7/10 from cramping)

Anxious about how

much she is bleeding

Vaginal pain ( hurts to

sit) feels like pressure

or throbbing

Fundus firm at U/U after provider intervention

Clots expressed by provider

Bleeding off, turn on and then back off when instructed by facilitator

RUNNER: As MD, come in to room and preform a manual evacuation of clots

MD ORDERS: Give 800 mg Misoprostol PR x 1 STAT Continue Pitocin at 125 mL/hr Continue monitoring with increased frequency of vitals/fundal checks and report any continued bleeding


State 5‐ Bleeding Stable and Patient Recovering VS: HR in the 90s, BP in the 100s/60s, RR in the teens and SpO2 in upper 98% on RA, Temp 98.6F LOC: Alert and oriented, less anxious, no longer dizzy/light‐headed Baby: Stable, awake and rooting



1. Performs repeat assessment of VS and fundal check

2. Promotes breastfeeding and educates patient about benefits of breastfeeding r/t to fundal tone

3. Provides emotional and educational support to patient and family regarding events

4. Documents data

Simulation Complete!

Responds to RN

questions.

Wants to breastfeed

after baby awakens.

Pain 2/10.

Bleeding off

One patient stabilizes turn on baby crying

RUNNER: None

MD ORDERS: None


DEBRIEF

The goal of the debrief is to provide the opportunity for the residents to share and reflect as a group on areas for improvement and recognize practice behaviors that demonstrate excellence. Remember to:

Remind residents that the debrief is a safe place and the purpose is for them to learn from their experiences

Try to use the video when it fits

Ask the family member their observations

Use standards as needed for clarity/guidance

Use “what if” questions

Embrace the silence

END with: What one thing are you going to take away from this experience?

The template below is available for groups that struggle to facilitate the debrief on their own… REVIEW OBJECTIVES OF THIS SIM:




Identifies signs and symptoms of postpartum hemorrhage using a systematic process



Maintains accurate and precise intake and out take records General

What worked, what didn’t work and what will you do differently next time?

What was the experience like for you?

What happened and why?

What did you do and was it effective?

Discuss your interventions (technical and non‐technical).

Were they performed appropriately

Were they performed in a timely manner?

How did you decide on your priorities for care and what would you change?

How did patient safety concerns influence your care? What did you overlook?

In what ways did you personalize your care for this patient and family members (recognition of culture, age, concerns, anxiety)?

Discuss your teamwork. How did you communicate and collaborate?

WHAT ARE YOU GOING TO TAKE AWAY FROM THIS EXPERIENCE?


APPENDIX

References:

Micromedix

AWHONN. (2014). Perinatal nursing. (4th Ed.). Simpson, K.R. and Creehan, P.A. (Eds.).

Philadelphia, PA: Lippincott Williams & Wilkins.

AWHONN. (2015). Quantification of Blood Loss: AWHONN Practice Brief Number 1. JOGNN, 44,

158–160; 2015. DOI: 10.1111/1552‐6909.12519


Initial Lab Results

Procedure Pt results Reference Ranger per

Facility

WBC 11.3

RBC 2.48

Hgb 13.2

HCT 34.6

ABO O

RH Positive

Antibody Screen Negative

Product Red Blood Cells

Unit ID W 141609 870524

Interpretation Compatible

Product Status Cross Matched

GB Strep DNA Negative