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Part 1: Simulation Case Planning Information.

Course or Event Name: (Open for viewing in Outlook)

Care of a Serious Contagious Disease patient

Scenario Title: (major event in the scenario- not for display)

Simulation 1 of series of 4

Patient Name (Cerner or Other)RequestorScenario Developer(s)Content expert (s)Unit reps.Sim specialist/consultantEducatorOther

Jessica McClusky & Vickie SlotEmergency Preparedness, Infection Prevention

Vickie Slot

HERT Team, Mark VanDykeUnits/ Departments Involved SCD team, Infection Prevention, Emergency Preparedness, HERT team

Target Group(s)How many/eventProfession 1/NumberProfession 2/NumberProfession 3/Number

Designated SCD team1x/yearSCD Team RNs-?HERT Team-?ICU MDs-?

Setting/Location of Activity in-situ Simulation lab Room(s) 9 CenterScheduled / Unannounced

Go live/first event dateFrequency (single, multiple, series) Part 1 of quarterly training seriesEstimated Total Event/course TimeDidactic:Learner orientation:Simulation:Debriefing:

4 hours?15-20 minutes4 hours1 hour

Estimated Total Simulation TimeResources Needed

Sim Lab/Room type set up Assigned isolation rooms in houseManikin(s) task trainers/other/SP Medium fidelity Manikin with voicePreferred Dates and TimesPersonnel Needed Confederates: Sim Operator Sim Educator Assessor Standard patient

Vickie SlotSimulation team/HERTHERT/IP/EP/Sim

Supplies/Props Needed/files (x-ray) Supplies –Infection control: exact PPE, Trash bins, scrubs, 3-4 containers bleach wipes for room and anteroom, hand sanitizer (auto dispenser) in room and ante room, mat for floor, sharps container, sign in log, ultimate precautions sign, red tape for floor (clean zone), disposable scissors, bottle bleach disinfectant for linen bags

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PPE- several sets for in and out of room (scrubs, shoes, full body suits, PAPRs, gloves)

Patient care items: 2 name bands, consent forms, pt. gowns, linen, thermometer, stethoscope, IV bags and pump, mocked up carts for anteroom

Medical equipment: IV, room preparation checklist, admission order set, oral meds (Acetaminophen and Zofran)

Labs: phlebotomy supply bag, blood draw equipment, containers to place EBV state test and/or regular lab bins, bags to place labs in, specimen labels, angiocaths

Simulation Supplies: IV arm and blood, headset for audio, simulated monitor and SimPad,

Nursing: Ascom phone, bin for passing supplies from ante room to pt. care area

Environment: room supplies removed, signage on doors- log in and ultimate precautions, iPad,

Room/Patient set up Blood in Manikin arm, doffing area marked with tape, bleach wipes in room, fill trash bins half full, patient in bed with patient gown on, auto hand sanitizers in room and anteroom, computer in anteroom for nurse charting, HERT buddy checklists in anteroom for donning and doffing, patient hooked up to monitor, vital signs equipment at bedside, sign-in log in anteroom, patient care/lab drawn items stocked in room, bin for supply passing in anteroom, ipad in room

Part 2: Course/Event Information

Educational RationaleCurrent Gap/Safety Issue/Problem/Training Need (example orientation, medication)

Spectrum Health has the approval to develop a serious contagious disease (SCD) unit, with the possibility of caring for patients with Ebola, SARS, MERS, etc.

Staff volunteering for the SCD team will need training in the care of these types of patients In cases such as Ebola, PPE and care procedures are specialized and unfamiliar to the staff Because of the virulence and risk associated with SCDs, the SCD team will need scheduled, recurrent training

sessions to stay competent in patient care and self-protection

Overall Simulation Goal- state in broad terms what you hope to accomplish

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Practice the nursing care for a patient with a SCD such as Ebola. Determine effectiveness of standard work protocols that are currently in place. Provide staff with experiences with new equipment and procedures needed for these patients.

Participant Objectives: Demonstrate proper donning and doffing of full SCD PPE Perform a full assessment of an SCD patient utilizing all necessary equipment Demonstrate proper procedure for passing supplies in and out of patient room Demonstrate proper technique for a patient blood draw Prepare blood specimen for transport to lab Demonstrate appropriate waste bagging and disposal Demonstrate room cleaning protocol Demonstrate teamwork Demonstrate safe patient care practices using call outs and repeat backs Demonstrate empathy through positive patient emotional support Evaluate current standard work protocols for effectiveness

Case summary of events:

Team of 4 RNs will don appropriate SCD PPE in preparation for a suspected Ebola admission. Working in teams of 2, with the other 2 RNs functioning as observers, the participants will perform a full assessment of patient using necessary equipment. The nurses will practice verbally calling out their assessment findings to a charting buddy. Various standard work protocols will be demonstrated, including with passing supplies in and out of the room, drawing the patient’s blood, preparing the blood specimen for transport to lab, waste bagging and disposal, and room cleaning.

Additional learning opportunities include working as a team, practicing observing to make sure caregivers do not turn their back to the patient or contaminate themselves, effective communication with additional services (EP, IP, MDs) as needed. A short debrief will occur after each standard work section, with a complete debrief before switching pairs.

The observing pair will be responsible for evaluating the caregivers for any potential contaminations, breaches in protocol, and accuracy of following standard work. Check-lists will be provided for this purpose.

After 2 hours, the teams will switch roles with the patient care RNs becoming the observers, and the observers providing patient care.

Pre-requisite knowledge, skills, policy read, Didactics, SHLIO prior to class. Pre-test

Donning and doffing of appropriate PPEEbola/SCD didactic session to be completed prior to simulation participation. This will include epidemiology, disease progression, treatments, nursing care, equipment use, standard work, and PPE practice.

Critical Learner Actions – List of correct steps1. Don PPE with buddy

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2. Greet and assess patient3. Verbal call outs for charting4. Order review5. Lab draw6. Lab packaging7. Supplies passed in and out of room8. Waste bagging and disposal9. Routine room cleaning10. Safety behaviors with buddy call outs (“NAME, STOP”)11. Doff PPE with buddy

Future Courses for TrainingSimulation 2: Review of Ultimate Precautions and PPE Donning/Doffing. Activities to be included in simulation are: patient assessment, charting, medication administration, passing supplies in and out of room, room cleaning, providing patient emotional support, spill clean up, linen and patient gown change, managing a patient assault to nurse

Simulation 3: Review of Ultimate Precautions and PPE Donning/Doffing. Activities to be included in simulation are: patient assessment, charting, medication administration, passing supplies in and out of room, room cleaning, providing patient emotional support, blood draws and specimen packaging for transport, waste bagging and disposal procedures, post mortem care

Simulation 4: Review of Ultimate Precautions and PPE Donning/Doffing. Activities to be included in simulation are: patient assessment, charting, medication administration, passing supplies in and out of room, room cleaning, providing patient emotional support, spill clean up, linen and patient gown change, managing the high acuity patient (intubation, CRRT, etc)List References Used for ScenarioReal pt. case

Please see Spectrum Health Infection Prevention website for most up-to-date Standard Work documents and order sets

CDC, WHO, Emory, Team Stepps, HPI Safety

Madariaga, M. G. (2015). Ebola virus disease: A perspective for the United States. The American Journal of Medicine, 128(7), 682-691. doi: 10.1016/j.amjmed.2015.01.035

Liddell, A. M., Davey, R. T., Mehta, A. K., Varkey, J. B., Kraft, C. S., Tseggay, G. K., … Uyeki, T. M. (2015). Characteristics and clinical management of a cluster of 3 patients with Ebola virus disease, including the first domestically acquired case in the United States. Annals of Internal Medicine. Retrieved from http://annals.org/article.aspx?articleid= 2292050. doi: 10.7326/M15-0530

Lyon, G. M., Mehta, A. K., Varkey, J. B., Brantly, K., Plyler, L., … Ribner, B. S. (2014). Clinical care of two patients with Ebola virus disease in the United States. New England Journal of Medicine, 371(25), 2402-2409.

Palmore, T. N., Barrett, K., Michelin, A., Ramsburg, A., Lee, L. M., … Henderson, D. K. (2015). Challenges in managing patients who have suspected or confirmed Ebola virus infection at the National Institutes of Health. Infection Control & Hospital Epidemiology, 36(6), 623-626.

Smith, P. W., Boulter, K. C., Hewlett, A. L., Kratochvil, C. J., Beam, E. J., Gibbs, S. G., … Schwedhelm, M. M. (2015). Planning and response to Ebola virus disease: An

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integrated approach. American Journal of Infection Control, 43, 441-446. doi: 10.1016/j.ajic.2015.01.019

Evaluation Plan: (Develop this Early) Participant/Event

1. Reaction 2. Learning 3. Practice change 4. Impact or pat outcomes 5. ROI

Scenario Implementation Date: Last Reviewed:

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Part 3: Facilitator Script (Preparation and Handover Report)

Simulation Preparation Patient Information Scenario Handover Report

Preparation:

Supplies –Infection control: exact PPE, Trash bins, scrubs, 3-4 containers bleach wipes for room and anteroom, hand sanitizer (auto dispenser) in room and ante room, mat for floor, sharps container, sign in log, ultimate precautions sign, red tape for floor (clean zone), disposable scissors, bottle bleach disinfectant for linen bags

PPE- several sets for in and out of room (scrubs, shoes, full body suits, PAPRs, gloves)

Patient care items: 2 name bands, consent forms, pt. gowns, linen, thermometer, stethoscope, IV bags and pump, mocked up carts for anteroom

Medical equipment: IV, room preparation checklist, admission order set, oral meds (Acetaminophen and Zofran)

Labs: phlebotomy supply bag, blood draw equipment, containers to place EBV state test and/or regular lab bins, bags to place labs in, specimen labels, angiocaths

Simulation Supplies: IV arm and blood, headset for audio, simulated monitor and SimPad,

Nursing: Ascom phone, bin for passing supplies from ante room to pt. care area

Environment: room supplies removed, signage on doors- log in and ultimate precautions, iPad,

Handover Report:

Date of admissionName John Smith Age 45 Gender/Race MWeight 90kg Height 6ft Allergies NKA

Dr. Names/Diagnosis Rule out Ebola

Cerner Patient Name John Smith

Orders: Ultimate precautions, limit blood testing to absolute clinical necessity to avoid operator exposure to blood

Labs: POC CMP, POC Malaria, Platelet Estimate, POC WBC, Ebola PCR

Profile

Meds: Tylenol, anti-nausea

Case Information:

History of Present Illness- Medical worker from Doctors without Borders, back from Liberia for 4 days. C/o fever, nausea, abdominal pain. Contact with Ebola patients while wearing PPE

Past Medical History- none

Past surgical History- none

Past Social/family History- married, 3 children

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Roles Assigned:

2 primary RNs 2 observing RNs

o Function as ante room RNs HERT team member Voice of patient

Confederate Brief:

See attached scripts for each scenario.

Set learners up for success!! The briefing is extremely important for successful simulations.

Learner Brief: We will give you an opportunity to take care of a patient with high risk for Ebola. We have provided clinical equipment to work with and want you to do as much as you can.

1. Learner want to know what they are participating in and why.a. This is a simulation where we would like to try out some processes of care for Ebola patients. We have a couple hours set aside to work on nursing work in the

clinical environment with an Ebola patient. This may be difficult or easy for you. Focus on improving your practice whatever level it is at.b. Specifically our objectives are to take all steps to minimize the risk of disease transmission for yourself and other people while performing clinical tasks. We

want to introduce you to the roles (HERT, nursing 1 & 2), look at communicating effectively with members of the HC team,c. We ask that you treat this like a real patient. Talk to your patient and family. We ask you to treat this as if it were real. If you are confused about how to work in

the simulation environment, you may ask questions.

2. Learners want to know YOUR role in the simulation.a. I/we will be watching the simulation and facilitating discussion afterwards.b. We are not here to evaluate your performance, but we will give our observations about what happened.c. We will learn about the standard work and can use it to improve our processes.d. Explain checklists or recording forms that a facilitator might be using.

3. Learners need to know how to interact with the equipment and manikins. (may use simEssential orientation scenario)a. You will use all the isolation precautions. Here is your PPEb. How to use the simulated monitor etc.c. Show where to find equipment, (meds, use Cerner, oxygen, crash cart, scan drugs, hang IV whatever you expect)

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d. For part of assessment not obvious, ask for assessment data (example- neuro, skin changes, color, pupil changes, )

4. Learners will need to know how to perform in a simulation.a. We would like 4 nurse participants to start. 2 in room and 2 in ante-room, need HERT team member, patient/manikinb. You may ask for whatever equipment, procedures, or services you want. (labs etc).c. Explain communication (how to call resident, phones,)d. Ask for any questions

5. Give handover report to start the simulation (include time in shift)

Here are the Rules for our Infection Control Rooms:

Follow all SW as much as able

Ensure 200 and 300% accountability especially r/t infection control practices which are detailed and specialized for this viral hemorrhagic disease.

Report all accidents or near misses

As a healthcare worker who has stepped up to take care of these patients. We are responsible to sign in and out. Keep track of everyone entering this room and sign in here.

When doffing. Do not hurry. It is a very detailed and deliberate procedure. Remove gear slowly so you do not contaminate yourself or aerosolize the virus. Remember though, A HERT Team member will be monitoring your safety at all times when you work with Ebola patients.

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Part 4: Scenario Progression Outline (Storyboard) This section will be completed by simulation center staff

Scenario Overview: Patient at high risk for Ebola is admitted to 9 Center. Nurses will do assessment and start basic care including lab draws, cleaning room, waste bagging, and passing supplies in and out

State 1: Patient Status Patient is currently stable. c/o nausea, chills. Fever controlled with antipyretics at this time.

Roles and Scripts

Report given: Mr. Smith is a medical missionary from Doctors without Borders, who has just returned from Liberia 4 days ago. C/o fever of 38.6*C, abdominal pain, nausea. Fever has been brought down to WNL with 1,000mg of Tylenol taken orally.

News reporter calls into room and requests to talk to patient. RN must verify who is on the phone and correctly direct them to call the command center for any information.

See attached scripts for specific examples and more information

Participant Actions:

Don PPEReceive reportSign logIntroduce self and assess patientCall out assessment findingsTake full vital signsDraw ordered labs (EVD screen) and package for transportPass supplies in and out of roomWaste bagging and disposalRoutine room cleaningEmotional support provided to patientTeamwork and safety behaviors utilizedDoff PPE with HERT buddy

Teaching Points:Appropriate PPE for room and ante roomShift planning- bring in all anticipated supplies when entering for the first timeEveryone in contact with patient must sign long- HERT member responsible for log managementRoles for RN caregiver/HERT/RN buddy clearly definedDiscuss reason for Tylenol instead of IbuprofenAssessment focuses on I&O, fluid replacement, symptom progression, emotional state, lung and heart sounds, N/V/DInfection Prevention gives final word on family and visitors.NO calls into patient room. All calls through command center

Operator: Fatigued, mildly anxious, hoping Ebola screen in negative

o c/o nausea, chills, muscle aches, fatigue, no appetite. May use medical language since you are a physician

o V/S 37.2*C, 110/62, 90HR, 24RR, 97% on RA

o Patient is only mildly anxious throughout scenario. Asks frequent questions, wants to be kept updated medically. See attached scripts for additional information and comment examples

Trigger(s): 2 hours pass. Debrief section immediately before switching roles

State 2: Patient Status: Patient is currently stable. c/o nausea, headache, chills, fever, anxious.

Roles and Scripts

Report given: Mr. Smith is a

Participant Actions:

Receive report

Operator: patient is not feeling as well as previous shift. C/o chills/body aches

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medical missionary from Doctors without Borders, who has just returned from Liberia 4 days ago. C/o fever, abdominal pain, nausea, headache. Tylenol available to be given anytime

Doctor arrives to report that Ebola screen is positive to patient.

Family arrives and wants to see patient. Anxious. RN to provide education to family member on visitation policy and to facilitate iPad FaceTime between patient and family

See attached scripts for specific examples and more information

Sign logIntroduce self and assess patientCall out assessment findingsTake full vital signsAdminister Tylenol for feverDraw ordered labs (chems)Pass supplies in and out of roomWaste bagging and disposalRoutine room cleaningEmotional support provided to patient after news of EVD positive testFacilitate iPad FaceTime and educate family on visitation policyTeamwork and safety behaviors utilizedDoff PPE with HERT buddy

Teaching PointsAppropriate PPE for room and ante roomShift planning- bring in all anticipated supplies when entering for the first timeEveryone in contact with patient must sign long- HERT member responsible for log managementRoles for RN caregiver/HERT/RN buddy clearly definedDiscuss reason for Tylenol instead of IbuprofenAssessment focuses on I&O, fluid replacement, symptom progression, emotional state, lung and heart sounds, N/V/DWho is responsible for informing patient of EVD positive status?Infection Prevention gives final word on family and visitors.iPad will be utilized for patient/family communicationLab EVD PCR may not be positive until 3 days after symptoms appear. A negative result must be repeated 3 days after symptoms appear to confirm.

returning. Fever returns. Ebola screen positive, causing increased anxiety

o c/o nausea, chills, muscle aches, fatigue, no appetite. May use medical language since you are a physician

o V/S 39.2*C, 108/60, 95HR, 26RR, 94% on RA

o Anxiety increasing. Ask frequently to see family. See attached scripts for additional information and comment examples

Trigger(s): 2 hours pass. Move to full PPE doff, followed by full debrief.

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Part 5 Debriefing Session Script

Facilitator names:

Debriefing Questions:

Overall feel of simulation Comfort with calling each other out/pointing out standard work breaks Feelings of concern/fear Issues with equipment Concerns about current standard work/suggestions for improvement Teamwork successes

Critical Actions:

1. Don PPE with buddy2. Greet and assess patient3. Verbal call outs for charting4. Order review5. Lab draw6. Lab packaging7. Supplies passed in and out of room8. Waste bagging and disposal9. Routine room cleaning10. Safety behaviors with buddy call outs11. Doff PPE with buddy

Objectives: (cut and paste if desired)

Demonstrate proper donning and doffing of full SCD PPE Perform a full assessment of an SCD patient utilizing all necessary equipment Demonstrate proper procedure for passing supplies in and out of patient room Demonstrate proper technique for a patient blood draw Prepare blood specimen for transport to lab Demonstrate appropriate waste bagging and disposal Demonstrate room cleaning protocol Demonstrate teamwork Demonstrate safe patient care practices using call outs and repeat backs Demonstrate empathy through positive patient emotional support Evaluate current standard work protocols for effectiveness

Teaching Points:

See didactic materials for teaching information on EVD. See Infection Prevention webpage on InSite for most up-to-date standard work procedures and materials.

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Scripting, Scenario 1

Patient: You are a physician who has returned to the US after caring for Ebola patients in Liberia with Doctors without Borders. You have done many mission trips like this before, but this was your first experience with Ebola patients. You reported yourself immediately when you began having symptoms, but do not think you ever breached PPE protocol while in Liberia. You are a little concerned about your symptoms, but think the “hype” is unnecessary, as you probably just have malaria.

When speaking to the nurses, you may use medical jargon, quiz the nurses on their assessment skills, joke/tease. Ask a lot of clarifying questions and have the nurses explain the reason for every action.

Examples: “What precautions are you taking when drawing my labs? Why?” “Why are you calling out your assessment findings? Can’t you just chart them yourself?” “You think my lungs have crackles (or whatever sound the RN reports)? Are you sure? Can I just listen myself really quick?” “What is the purpose of bagging all this stuff so carefully? Where do you throw that out?”

If RN gives you the phone when the reporter calls, become angry at your lack of privacy and HIPAA violations.

Reporter: *Calls into room. RN answers. Does NOT identify self. “Hello, may I please speak with John?” If questioned by nurse, claim to be “a family member.” Do NOT provide details. If heavily pressed by nurse, admit to being a reporter from WOOD TV. Try to interview RN.

Examples: “Can you tell me if John has Ebola?” “What is his medical status at this time?” “Does the staff feel as though they are in danger while taking care of John?” “Is the public in danger?”

*RN should answer NO questions and accurately verify who is on the phone. Reporter should be directed to call the command center for any information.

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Scripting, Scenario 2

Patient: You are a physician who has returned to the US after caring for Ebola patients in Liberia with Doctors without Borders. You have done many mission trips like this before, but this was your first experience with Ebola patients. You reported yourself immediately when you began having symptoms, but do not think you ever breached PPE protocol while in Liberia. You are a little concerned about your symptoms, but think the “hype” is unnecessary, as you probably just have malaria.

Before doctor visit: You may follow the same scripting for Scenario 1 until the doctor arrives. After doctor visit: You become much more anxious and irritated with the poor job the doctor did at

describing your plan of care. Seeing the disease in Africa, you are fully aware of the disease progression but want to know what modern medicine in the US can do to help you through it. You ask constant questions of the nurses related to treatment plan.

o Examples: “What is next?” “Should you be giving me special medications?” “How long until I start to feel very sick?” “How long am I going to be here?” “What is my full treatment plan?” “What medications did the other patients who survived receive?”

You then begin to get more emotionally distraught and withdrawn. You are concerned about your family.

o Examples: “Can I tell my family?” “Do they know?” “Can I see them?” “How long do I have to be away from them?”

Doctor: You are tasked with telling John that his EVD screen has come back positive. You are not happy about the task, but since he is a physician himself, you think he will do best with a simple, direct approach.“Hi John, I am Dr. Ice. I am here to let you know that your Ebola test has come back positive. Here in the United States we have great healthcare, as you know, so we will be doing our best to help you through this. Most treatment is supportive care, so we will add IV fluids and oral rehydration as needed. I am just a phone call away if the nurses need me.”Immediately get up and leave, leaving no time for questions from the patient.

Family: You have arrived after an update from the doctor tells you that John has been confirmed as positive for Ebola. You are extremely anxious, convinced he is going to die, and demand to see patient.

Examples: “I NEED to see John now! What if I never get the chance to see him again? I don’t care if I get Ebola too, I need to see him!” “Is he ok? What treatment is he getting? What are his chances of survival? How can I talk to him?”

*The nurse should educate family on the visitor policy and reasons behind it. The nurse should then facilitate an iPad FaceTime between the patient and family.

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SCD Simulation Observer Checklist YES NO NA Observer notes

Takes report and asks clarifying questions

Introduces self to patient

Completes full assessment

Correctly utilizes necessary equipment such as electronic stethoscope

Calls out all assessment findings to charting buddy

Passes supplies out of room with no contamination of buddy

Accepts supplies into room with no contamination of buddy

Successfully draws patient blood for labs

Correctly packages labs for transport

Correctly bags and disposes of patient waste

Cleans room thoroughly

Adheres to standard work where available

Utilizes resources when neededo Calls IP/EPo References standard work

Does not turn back to patient at any time

Causes no contamination during patient care

Updates and provides emotional support to patient while providing care

Works as a team with buddy RN

What did the patient care group do well?

What would you have done differently?

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EvaluationPre-Simulation Knowledge Self-Assessment

Please rank your current level of confidence with each of the following activities using the scale provided:

1. Donning Ultimate Precautions PPE 1 2 3

2. Doffing Ultimate Precautions PPE 1 2 3

3. Perform a patient assessment utilizing electronic stethoscope 1 2 3

4. Passing supplies in and out of patient room without contamination 1 2 3

5. Packaging a high risk blood specimen for transport to outside lab 1 2 3

6. Appropriately bag and dispose of patient waste 1 2 3

7. Perform routine room cleaning based on protocol 1 2 3

8. Use safety behaviors, call outs, and repeat backs 1 2 3

9. Provide appropriate emotional support for a confirmed or suspected SCD patient 1 2 3

*Save all evaluations for comparison of participant confidence with patient care activities throughout simulation series

1 = Not confident 2 = Confident 3 = Very confident

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EvaluationPost-Simulation Knowledge Self-Assessment

Please rank your current level of confidence with each of the following activities using the scale provided:

1. Donning Ultimate Precautions PPE 1 2 3

2. Doffing Ultimate Precautions PPE 1 2 3

3. Perform a patient assessment utilizing electronic stethoscope 1 2 3

4. Passing supplies in and out of patient room without contamination 1 2 3

5. Packaging a high risk blood specimen for transport to outside lab 1 2 3

6. Appropriately bag and dispose of patient waste 1 2 3

7. Perform routine room cleaning based on protocol 1 2 3

8. Use safety behaviors, call outs, and repeat backs 1 2 3

9. Provide appropriate emotional support for a confirmed or suspected SCD patient 1 2 3

*Save all evaluations for comparison of participant confidence with patient care activities throughout simulation series

1 = Not confident 2 = Confident 3 = Very confident