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Simulated Patient Template

Title: Stroke part 2 ____________________________________________________________________

Location/Hub: La Trobe University Bendigo______________ Date: __11_/__9_/2014

Version: 1.0 Author: Kirrian Steer. Co- authors: Chloe Lyons & Therese Worme Validated by: TBA

Scenario overview:

Estimated Simulation Time: 45 min Estimated Debrief: 45-60 min

The patient has been brought in by ambulance after suffering a suspected stroke while using a cycle

ergometer at an exercise physiologist consultation. The paramedics handover to the ED staff and the

patient is assessed, stroke treatment protocol is initiated, and the diagnosis and management plan is

communicated to the patient.

Learners:

Nursing x

Undergrad x Paramedicine x

Post Grad Medicine x

Others (please list) Allied Health (state)

___________________________________ _________________________________

Learning objectives for Simulation:

1. Work with individuals of other professions to maintain a climate of mutual respect and shared

values.

2. Use the knowledge of one’s own role and those of other professions to appropriately assess and

address the healthcare needs of the patients and populations served.

3. Communicate with patients, families, communities, and other health professionals in a

responsive and responsible manner that supports a team approach to the maintenance of

health and the treatment of disease.

4. Apply relationship-building values and principles of team dynamics to perform effectively in

different team roles to plan and deliver patient-/population-centered care that is safe, timely,

efficient, effective, and equitable.

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Faculty requirements:

Technician: Name: ________________________________________________________________

Brief: Name: _____________________________________________________________________

Debrief: Name: ___________________________________________________________________

Confederate/s Name: ______________________________________________________________

Simulated Patient:

Participant Roles

Paramedic students x 2 Nursing students x2 Confederate emergency triage nurse x1 Confederate emergency medicine consultant x1

Clinician task (including briefing to trainee):

The scenario begins with paramedic student’s handover of the patient to the emergency department

triage nurse. After being allocated a cubicle within the emergency department, the paramedic students

transfer the patient from the stretcher onto the ED bed, and handover to the nurses. The nurses begin

the initial assessment of the patient and then handover to the treating medical officer (MO) when they

arrive. The nurses perform a baseline assessment including vital signs and neurological observations,

blood tests, a BSL and an ECG.

The MO orders an urgent computer tomography of the brain (CTB), and contacts the MO to perform the

NIH Stroke Scale, and contacts neurology via Telemedicine. The patient is not eligible for thrombolysis,

despite diagnostic results revealing an ischaemic stroke. The decision is made to treat the patient

conservatively, and scenario concludes when this has been communicated to the patient.

Setting:

Emergency department Scenario Endpoint:

When patient is informed of diagnosis and management plan by MO or T=45 min

Safety/Risk Considerations:

Manual handling/patient transfer. No invasive procedures to be performed on SP Resources required: Simulated ED environment

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Equipment:

Required No. Collected

Paramedic equipment – trolley, bags etc.

Patient gown 1

Treatment trolley – stocked 1

Blood pressure cuff/Sphygmanometer 1

Stethoscope 2

Tympanic thermometer 1

Venepuncture arm, BSL kit & fake blood for tubes/BSL 1

Portable ECG machine & ECG stickers/dots (packet) 1

Linen skip 1

SimOxy (Simulated Sp02 probe) 1

Pen torch 1

Gloves on wall (box of all three sizes) 1

Clock – adjusted to simulation time 1

Microphone (for triage scene only) 1

Patient pat slide 1

Debug & Isowipes 1

Computer and phone (prop triage computer & phone) 1

Plastic patient bag 1

Electric razor 1

Vacutainers blue, yellow, grey, purple 1ea

Vacutainer sheath

Vacutainer needles

Alcohol wipes

Tourniquet

Cotton balls

Tape

Saline 10ml

10 ml syringes

Drawing up needles

Documentation:

Required No. Collected

Emergency Department Record/MR2/93

Patient labels/stickers on sheet 1

Patient ID band 1

Adult Neurological Chart 1

12 Lead ECG – Sinus tachycardia 90bpm 2

Confidentiality/Consent forms for participants 6

Radiology and Pathology forms 1

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Scenario Events

Scene 1 Layout/Room Set up – TRIAGE

Desk set up with 2 chairs, laptop, mouse, calculator and phone

Stationary accessories around computer such as – pen jar, sticky note pad, stapler, calculator, debug,

moisturizer, tissues and adult Triage forms. Also need to have a pen torch and stethoscope here.

Patient will be already cannulated by paramedic students (x1 mock IVC in each arm).

Paramedic students will bring the patient in on a stretcher into the Emergency Department’s Triage.

One paramedic student will stay with the patient by their side, and the other will hand over to the nurse.

The triage nurse will listen to the paramedic student, and ask questions where appropriate in order to

appropriately categorise the patient. The Triage nurse will document the paramedic’s hand over and

briefly perform his/her own assessment to ensure there has been no deterioration on route.

Information collected will then be entered into the computer system and the Triage nurse will announce

over the microphone that the patient is a “category 2”.

Scene 2 Layout/Room Set up – Emergency Cubicle

Patient bed empty and enough space for ambulance trolley to move beside for transfer.

Bedside/patient trolley at end of bed with documentation on, treatment trolley (stocked) within room,

portable ECG machine in corner, linen skip, bedside desk with isowipes/debug on, ARC basic life support

guidelines laminated on wall above head of bed. Small communication whiteboard and marker above

head of bed for staff to use. Pat slide accessible. Vital Signs equipment on bedside desk or hanging on

bedpole, easily accessible for nurses.

After being allocated a cubicle the paramedic students then transfer the patient onto an emergency bed

with the assistance of two nurses. Once the patient is transferred to the emergency bed and once the

nurses have all the required information from hand over, the paramedic students then leave the room

to go and write up their report. The nurses begin their care by undressing the patient into a hospital

gown, and attaching a patient ID band after confirming the details are correct.

The two nursing students will begin the initial patient assessment by performing a baseline set of vital

signs including: blood pressure, heart rate, temperature, spo2sats, respiratory rate and chest

auscultation. They should then proceed to perform a neurological assessment including: GCS,

assessment of speech through conversation, checking pupil reactivity/size, performing limb strength

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tests and identifying any deficits such as the facial droop/numbness. The nurses will provide

reassurance to the patient through therapeutic communication, and offer to obtain analgesia for the

patient’s headache if required.

The MO arrives into the emergency cubicle after these baseline assessments have been performed,

asking for a handover on the patient and current situation. The nurses will introduce the patient,

reiterate the information obtained from the paramedics to the MO, the results of the assessments they

have performed, where they are up to in providing care. The MO will direct the nurses to take some

baseline blood tests, an ECG, and informs then he is going to order an urgent CTB. The scene will end

with the MO informing the patient he is going to have to ask a series of questions and perform his own

assessment, whilst awaiting the CTB scan.

Pause scenario – inform participants that the patient has now returned from the CT scan, and has been

assessed by the MO who has consulted with neurology in Melbourne.

The nurses will perform another set of vital signs and a neurological assessment, whilst providing

reassurance through therapeutic communication/patient interaction. The MO informs the nursing staff

the patient is not for thrombolysis, and is for conservative management on the acute stroke unit. The

MO informs the patient of the diagnosis, and what the management will be from here. The simulation

will end after the patient asks the MO to contact his partner for him, with the MO accepting this duty

and reassuring the patient.

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Chris Potter – Simulated Patient Role

Age: 62

Build – Heavyish

Right handed

Occupation: retail sales – floor coverings

Ethnicity Caucasian Special Features – facial droop, weakness of R arm and leg

Educational level: high school Relationship Status divorced (amicably), re-partnered recently

Socioeconomic status – lower middle class

Patient Behaviours:

The patient should remain laying down on the ambulance trolley/hospital bed, and have minimal

response on the right side of body when assessed by the triage nurse. The patient is quite fearful and

anxious. They have a lot of difficulty speaking – slurred speech and difficulty finding the right words. The

R arm and leg are very weak and can only be moved slightly. Cannot hold or grip objects with R hand.

Cannot walk. There is a R facial droop and eyes are deviated to the L.

Be directed by the nursing and paramedic students in transferring onto the hospital bed, and if asked to

assist by sliding across with your stronger left side, go ahead and do so.

Opening lines/ questions/ prompts:

Ask the paramedics/nursing staff if you are going to be ok, seeking reassurance as you are anxious and unsure of what is happening to you. Conversation/questions suggested:

Answer some of the nursing student’s questions with a delayed response at times, and slurring of your words. You can give the incorrect answer to questions about time or place, or say “I don’t know, or I have forgotten” as it is expected you are slightly confused. When questioned about any pain, report that you are suffering from a headache, if asked to rate the

score out of 10, rate it at ‘”about a 3/10”. If offered analgesia, kindly decline and say “It’s not that bad

that I need medication, but I will let you know if it gets worse”

Exhibit a level of concern and anxiety, but not so much that it takes away from the simulation itself.

Ask for reassurance with questions such as:

“Am I going to be ok? I won’t die will I? “ “Do you think I will be able to walk again? I can’t move my right leg, that’s not good is it?” “How long do you think I will be in hospital for?”

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Patient’s reason for interaction (presenting problem) including their ideas and concerns

The patient suffered a suspected stroke while at an exercise physiologist consultation. The patient is

very anxious and frightened.

Background Information

Family Situation and relationships: Divorced, has two adult children. Son is a diesel mechanic in WA,

Daughter is a primary school teacher in suburbs of Melbourne, currently on maternity leave after having

second child 3 months ago. Has recently started dating

Family strengths and challenges: Has amicable relationship with ex-spouse. Has been seeing someone

for the last couple of months and might be getting serious. They have discussed living together but Chris

is worried about what the kids will say.

Medical knowledge and level of understanding - very minimal, layman’s terms only.

Prior experience with healthcare system –sees GP only when necessary. No prior hospital admissions

Communication style: co-operative but not very chatty.

Emotional expressiveness: frightened and anxious

Nonverbal behaviour and physical characteristics: Weakness of R side

Medical history -

Smoker – 20-25 per day for most of adult life. Has tried to quit a couple of times but never lasted more

than a month. Thinks it probably isn’t worth quitting now, all the damage will be done.

Alcohol - 1-2 glasses of wine or beer per night. Might have a few more on weekends.

No regular exercise – “I work on my feet all day and I just want to sit down when I get home”.

Hypertension – poor adherence to medication. Has been prescribed COVERSYL PLUS 1.25mg daily but

hasn’t started taking it (“I don’t want to be stuck taking tablets for the rest of my life”)

Family History – Mother is 83 and lives in a retirement village. She is reasonably independent. Father

had a fatal ‘heart attack’ 5 years ago age 79.

Social history

Works in sales in a floor covering shop (Floors Galore), has worked there for the past 16 years. Enjoys

the work, gets along well with colleagues.

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Diet

Breakfast – Coffee with two sugars, skips breakfast, has biscuits and coffee for morning tea at work.

Lunch – buys something from the cafe down the street, usually a meat and salad roll in summer or a pie

or in cold weather.

Dinner – Take-away or pre-prepared (frozen) meals a lot of the time. Makes more effort to cook on the

weekends. Will do a big roast or pasta meal and eat leftovers later in the week. Has dessert or snack

about an hour before bed; ice-cream, chocolate or biscuits usually.

Considerations in playing this role including wardrobe, make up and challenges:

Neat casual wardrobe (same as part 1). See patient behaviours for challenges. It will take a lot of

coaching and rehearsal to be able to reproduce the physical presentation of the patient when exhibiting

stroke symptoms.

Character attributes

Not at all Mild Moderate Concerning Severe

Anxiety 1 2 3 4 5

Shock 1 2 3 4 5

Confusion 1 2 3 4 5

Guilt 1 2 3 4 5

Sadness 1 2 3 4 5

Indecision 1 2 3 4 5

Assertiveness 1 2 3 4 5

Frustration 1 2 3 4 5

Fear 1 2 3 4 5

Anger 1 2 3 4 5

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Vital Signs for Simulation:

Unchanged throughout the simulation. The blood pressure and temperature will be carried out and

‘voice of God’ will communicate simulated vital signs. The heart rate and spo2sats will be pre-set on the

SimOxy, with all of the other vitals taken from the actual patient in the simulation.

GCS 14 (confused)

Pain Score 3/10 (headache)

BP 170/90mmHg

HR 90bpm

Rhythm Sinus

Spo2sats 97% on RA

RR Taken from pt

Temp Taken from pt

Pre-Simulation Event Checklist

Coach SP on behaviours/postures/emotions and demonstrate examinations/tests

Print documentation and complete fields where necessary

Ensure all resources (page 3-5) are available and set up.

Provide participant brief to confederates and learners

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Debrief Overview: (examples of questions)

How did the experience feel? _____________________________________________________

Describe how you were involved? _________________________________________________

What have you learnt from this patient? ____________________________________________

What will you take away from this experience? _______________________________________

How can you assist other health professionals in performing their role?

How could other health professionals assist you to perform your role?

Appendices:

Participant Briefs

References:

Australian Resuscitation Council Guidelines – Basic Life Support http://www.resus.org.au/public/arc_basic_life_support.pdfv National Stroke Foundation Australia – Clinical Guidelines http://strokefoundation.com.au/health-professionals/tools-and-resources/clinical-guidelines-for-stroke-prevention-and-management/ Bendigo Health – Hospital Policies for Staff

Assessment and Management of Hyperacute Ischaemic Stroke Patients Eligible for Thrombolysis (rt-PA)(2010)

Alteplase (rt-PA) for Ichaemic Stroke (2010)

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0

International License.

Acknowledgements

This template is a modified version of a template developed by Prof. Debra Nestel, Monash University.

Character Attributes table modified from Pascucci, R. C., Weinstock, P. H., O’Connor, B. E., Fancy, K.

M., & Meyer, E. C. (2014). Integrating actors into a simulation program: a primer. Simulation in

Healthcare, 9(2), 120-126.

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Appendix 1

Participant Briefs

Brief for nursing students: (x2)

You are nurses working in an Emergency Department, and will work together with a MO to deliver care

to a patient suffering an acute stroke. To refresh yourself on how to care for a patient suffering a stroke,

please refer to relevant resources, such as –

Chapter Thee: Early assessment and diagnosis, specifically 3.2 – Rapid assessment in the

Emergency Department, from the National Stroke Foundation Australia via –

http://strokefoundation.com.au/health-professionals/tools-and-resources/clinical-guidelines-

for-stroke-prevention-and-management/

Paramedics will bring your patient to the cubicle. Together you will help transfer the patient across onto

the emergency bed, and ask any relevant questions to the paramedic students. You will then proceed to

undress the patient into the hospital gown and attach the patient ID band after confirming the details

are correct. It is then expected you would perform a baseline set of vital signs and a basic neurological

exam. Once this baseline assessment has been carried out, you will then be working with a confederate

Medical Officer, whom will require a bedside ISBAR hand over of the patient and the current situation

from you. The MO will briefly assess and speak with the patient, and then direct you with what

assessments/tests will be required. Once the bloods, ECG and BSL have been performed, it is expected

that you continue to assess the vital signs and neurological state, providing reassurance and comfort

measures to the patient where appropriate.

Brief for Paramedic students

You will be required to transfer the patient into the Emergency Department, and hand over at Triage

desk to a RN. Once you have been allocated a cubicle, you will then proceed to transfer the patient onto

the emergency bed, with the assistance of two emergency nurses. After transferring the patient onto

the bed it is then expected you provide a bedside handover to the nursing staff, answering any

questions they have, and handing over any patient belongings.

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Brief for confederate Triage nurse

You will be required to take handover from the paramedic students at triage, asking any appropriate

questions and performing any assessments deemed necessary. It would be expected you ensure the

paramedic students have given you an accurate time of onset of symptoms, and description of the event

itself (eg. was there a headstrike/LOC, any seizure activity) alongside the patient’s normal physical

function/capabilities. After completing the relevant documentation it is expected you will then

announce on the microphone that there is a “Category 2 patient at Triage” in order to alert staff this

patient is a high priority, required to be seen within 10 minutes of arrival.

Brief for confederate Emergency Consultant

You are working within a busy Emergency Department, and will be required to provide direction to the

nursing students in caring for a patient suffering an acute stroke.

You will enter the simulation once the nursing students have performed a baseline assessment and vital

signs, directing them to perform an ECG, BSL, Bloods – FBE, U & E, CRP, LFT’s, Coag’s, and to prepare

the patient for and urgent CTB. You will write up an order for IV Morphine 2.5mg-5mg for the patient’s

headache, and Ondansetron 4mg IV for any nausea. You inform the patient that all these tests are

required urgently; as you are concerned the patient is suffering an acute stroke.

You will briefly talk with and asses the patient, confirming the neurological deficits described by the

nursing staff yourself. You will express the importance of the CT scan happening as soon as possible,

and then state you are liaising with the Medical Registrar and Neurology in Melbourne via telemedicine.

Once the patient has returned from radiology, you will then re-enter the room with the diagnosis and

plan of care. You will inform the nurses and patient the diagnosis is a stroke, and the management plan

will be for you to be admitted to the medical/stroke unit and then undergo further tests over the next

week. You can discuss with the patient that the tests are to try and determine the cause of the stroke,

to minimise the chances of it happening. You can inform the patient that you are unsure if he will ever

regain use back in the right side of his body, but stress that the allied health team including

physiotherapists will do everything they possibly can to maximise what function and mobility you have.

You inform the nursing staff (and document) that the patient is to be NBM (nil by mouth) until assessed

by the speech pathology team, and monitor the blood pressure closely to ensure it remains under 180

systolic. You advise the nursing staff that the patient will be further assessed by the Medical Registrar

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on the ward, and will be for a carotid ultrasound and echocardiogram when available. You also request

that the nursing staff can hand over to the ward that the patient will require a social work, occupational

therapist and physiotherapist review when appropriate.

Plan of care to be documented by MO

Transfer to Stoke Unit under the Medical Team

NBM until S/B speech pathology

Report if BP >180mmHg

For Carotid U/S and Echo

Minimum 2/24hrly neurological observations

Repeat bloods in am

Allied health R/V