Title: “Red in the Face” Interprofessional Simulation Case ...



Title: “Red in the Face” Interprofessional Simulation Case ScenarioTarget Audience: Medical students, medical residents PGY1, RN students, new RN orientees Learning Objectives for Provider Learners: Identify the appropriate vancomycin infusion rate for an adult patientIdentify the potential complications related to rapid vancomycin infusionRecognize signs and symptoms of red man syndrome/allergic reactionPrioritize treatments and interventions for red man syndromeCollaborate with the interdisciplinary healthcare team using SBAR communication and crisis resource management principles.Learning Objectives for RN Learners:Identify the appropriate vancomycin infusion rate for an adult patientIdentify the potential complications related to rapid vancomycin infusionRecognize signs and symptoms of red man syndrome/allergic reactionPrioritize treatments and interventions for red man syndromeImplement treatments and interventions for red man syndromeCollaborate with the interdisciplinary healthcare team using SBAR communication and crisis resource management principles.Learner Preparation:Prior to the simulation session, learners are encouraged to review the incidence and prevalence of MRSA, the treatments of HA-MRSA and CA-MRSA, the common side effects/adverse effects of treatment for MRSA, signs and symptoms of red man syndrome, treatment modalities for red man syndrome, and how to use SBAR and closed loop communication among healthcare team members.Faculty Preparation:The faculty should be familiar with the scenario branch points. The physiologic parameters on the patient simulator need to be changed by the faculty or simulation staff in response to the learners’ actions. The faculty should be prepared to discuss red man syndrome as one of the potential adverse effects of rapid vancomycin intravenous administration; differential diagnosis, the etiology, signs and symptoms of red man syndrome; appropriate treatment modalities for this adverse effect, differences between red man syndrome and anaphylaxis, as well as using SBAR and closed loop communication among interdisciplinary healthcare team members.Since this scenario is designed for interprofessional learners, faculty from each discipline should be present at the scenario as well as the debriefing.Learner Orientation to Manikin and Environment:The learners should be oriented to the manikin and vital signs monitor, as well as the room environment. The introduction should include: How to obtain vital signs on the manikinBreath sounds are normally present and can be auscultatedHeart sounds are normally present and can be auscultatedPulses can be palpated and pulse quality may change if the patient becomes hypotensiveBowel sounds are normally present and can be auscultatedSweating can be present Where to obtain basic hospital supplies: gloves, hand sanitizer, isolation gowns, water pitcher, cups, etc.Location of the telephonePhone number of the provider following the patient’s case Location of the medication cartLocation of the electronic health recordHow to access and/or enter orders on the electronic health recordRoles/Actors: The roles in this simulation case scenario are designed to maximize versatility for use in different disciplines and different levels of learners.RN learner role:Can be new RN orientee or RN student. Can also be acted by faculty or simulation staff.Provider learner role:Can be resident/medical student. Can also be acted by faculty or simulation staff.RN outgoing shift:Faculty/simulation staff can act in this roleScenario Background for Learners:HPI:Rob Paulson, a 68 year old male, was admitted to the med/surg unit last night for MRSA infection of a previously lanced leg wound. IV vancomycin has been ordered by the admitting care provider.PMHx:MRSA on leg, diabetes, COPDPSHx:Weight:Tonsillectomy, arm fracture, leg wound I&D75 kgMeds:Doxycycline 7 days po for CA-MRSA prescribed by PMDInsulin (Novolog)Proventil (bronchodilator)Flovent (inhaled steroid)Allergies:NKDAAlcohol/drugs/tobacco:Denies Social Hx:Retired, lives aloneScenario Background and Instructor Notes for FacultyAn actor will play the role the outgoing shift nurse, who is in a hurry to leave the hospital at change of shift to pick up his/her child from school. The nurse initiates the first dose of vancomycin, but in his/her hurry, neglects to infuse the vancomycin via IV pump at a slow rate. Instead, the vancomycin infusion goes in rapidly by gravity, causing red man syndrome in the patient. The learners will need to identify that the rate of vancomycin infusion is too rapid, identify the reaction, communicate effectively amongst the healthcare team, prescribe the appropriate treatments, and implement the appropriate orders.Optimal Management PathwayThe RN learner will need to:Identify that the medication is not on an IV pump and it should beIdentify the vancomycin infusion rate as too rapidStop the infusionRecognize patient condition is changingAssess and examine patientCommunicate effectively with the learner or actor in the provider roleCommunicate interventions with the patientImplement provider ordersThe provider learner will need to: Examine patientDiagnose red man syndromeConfirm the vancomycin infusion has been stoppedOrder O2 at 2L/min via NC, order PO H1 and H2 receptor antagonists (diphenhydramine 1mg/kg PO, cimetidine 4mg/kg PO)Provide orders verbally or enters orders in the electronic health record or other recordCommunicate effectively with the learners in the RN roleCommunicate plan of care with the patientAdvises patient of reactionIf the learner(s) manage the patient via the optimal pathway, the vital signs and patient status will return to baseline after the treatments are implemented.Potential Complication PathwaysIf the learner(s) do not follow the optimal management pathway, patient status will continue to deteriorate (See pages 4-6). In that case, the faculty may stop the scenario early and move on to debriefing.Equipment: SimMan 3G - In this particular scenario, the manikin has been modified to simulate the face/neck/upper torso skin flushing or erythematous rash of red man syndrome by placing red LEDs under the manikin’s skin. The LEDs, connected to a switch, should be turned on by a faculty or simulation staff on cue. The case cannot use a pre-moulaged manikin as the development of the skin flushing is not present on the team’s arrival.Contact Isolation” sign – place on door to patient roomIV Fluid – NSIV Medications –Vancomycin 1 gram in 250 mL NS hangingPO Medications –Diphenhydramine, cimetidineID braceletPhoneGloves Hand SanitizerDiaphoresis Nasal CannulaNon-rebreatherIsolation gownsPatient Chart Admission Sheet MAR Physician Order SheetTimeManikin Settings and ChangesDesired Learner Actions Actor Cues / PromptsTeaching Points0-3 minVS now : BP: 130/89RR: 16HR: 84Pulse Ox: 95%LOC:A&O x 3, calm, communicativePhysical Status Lungs: normalBS: positive x4Operator Verbal Sounds:I’m okay, my thigh hurts where they drained that thing. RN Learner:Gown and gloves prior to entering patient roomIdentifies patient and selfAssesses LOCObtains vital signsObtains historyChecks medication and rateRecognizes vancomycin infusion rate as too rapidStops vancomycin infusionNurse on outgoing shift:Tells RN learner: “I have to go pick up my kid from school. I just started the antibiotic, he’s stable, will you just double check everything for me?” Intentional error: allows vancomycin to infuse rapidly via gravityLeaves room in a hurry before RN learner can ask any questions or assess patientDiscuss:Importance of maintaining contact isolation.Importance of appropriate handoff procedureExample: Outgoing shift reviews health record with incoming shift, confirming patient background information, relevant health history, drug allergies, treatments/interventions ordered, treatment/interventions given or pending, lab tests, plan of care. The outgoing and incoming shifts should visualize and confirm medicated drips at the bedside.Appropriate Vancomycin infusion rate: infuse over 2-4 hours3-10 minVS change: CHANGE VS FIRST, THEN VERBAL REACTION (agitation, SOB)Sweating, switch on LEDsBP: 110/65RR: 22HR: 135Pulse Ox: 92%LOC:A&O x 3Operator Verbal Sounds:Becomes agitated and increasingly anxiousVS changes:See page 6 for VS changes in response to learner actionsRN Learner:Recognizes patient condition is changingContacts Provider Learner via telephoneCommunicates patient status to provider using SBARProvider Learner:Gowns and gloves prior to entering patient roomIdentifies selfExamines patientDiagnose red man syndromeCommunicates diagnosis and orders with RN learner using SBAROrders: O2 at 2L/min via NCDiphenhydramine75 mg POCimetidine 300 mg POEnters orders in the electronic health recordDiscusses diagnosis and plan of care with patientRN LearnerAcknowledges orders using closed loop communicationAdministers:O2 at 2L/min via NCDiphenhydramine 75 mg POCimetidine 300 mg POContinues talking to patientReassesses patientCommunicates patient status and implementation of orders with Provider Learner using closed loop communicationIf faculty/simulation staff is acting in the role of the provider:Orders:Diphenhydramine75 mg POCimetidine 300 mg POO2 at 2L/ min via NCEnters orders in electronic health recordDiscuss:Differential diagnosesSigns and symptoms of red man syndromeEtiology of red man syndromeTreatment modalities for red man syndromeDifferences between red man syndrome and anaphylaxisImportance of using SBAR and closed loop communicationExample of SBAR:S: Mr. Paulson, a patient here in room 1434 is in acute distress, he’s agitated, O2 saturation dropped to 92%, heart rate increased to 135, and developed an erythematous rash on his face.B: He is a 68 year old male admitted last night for MRSA infection of a leg wound. He just received IV vancomycin.A: I noticed that the vancomycin was infusing rapidly when he developed the symptoms. I stopped the vancomycin infusion.R: I would like for you to come assess him as soon as possible. When can you get here?Initial presentation of patientB/P 130/89, HR 84, RR 16, SpO2 95%BP = 110/65HR = 135RR = 22SpO2 = 92%Stops Vancomycin infusionBP = 115/70HR = 120RR = 12SpO2 = 93%Continues to be alteredO2 OnlyReturns to baselineBP = 90/60HR =130SpO2 = 85%Increased difficulty breathing, agitationNo treatment givenOptimal Management:O2, Diphenhydramine and Cimetidine , or just Diphenhydramine and O2RN Learner Critical Actions ChecklistCompeting Team_______________Red in the FaceCritical ActionsCriteriaScore1Sanitizes handsDoes NOT wash hands0Some members wash hands1All team members wash hands22Infection ControlDoes NOT gown and glove before approaching patient0Some members gown and glove before approaching patient (if more than 1 RN learner)1Gowns and gloves before approaching patient23Introduce Self/TeamDoes NOT introduce self/team0Introduces self/team2Vital Signs/Physical Assessment4Obtains vital signsDoes NOT obtain vital signs0Obtains vital signs partially or inaccurately1Obtains vital signs completely and accurately: Systolic BP 125-135Diastolic BP 85-95HR 80-90RR 14-18SpO2 95% 25Assesses Lung soundsDoes NOT auscultate lungs 0Auscultates anterior lung sounds1Auscultates anterior and posterior lung sounds26Assesses WoundDoes NOT assess wound verbally or physically0Assess wound verbally or physically27Checks Vancomycin infusion rateDoes NOT identify incorrect rate0Identifies incorrect rate28Stops Vancomycin infusionDoes NOT stop vancomycin infusion when patient condition changes0Stops vancomycin infusion when condition changes29Reassesses and recognizes changesDoes NOT recognize change 0Recognizes changes when patient speaks1Recognizes changes in physiologic condition2Communication and Teamwork10Team LeaderDoes not identify team leader verbally0Identifies team leader verbally211Team Member RolesDoes NOT maintain clearly defined team member roles0Maintains clearly defined team member roles212Uses closed-loop communication among healthcare team: 1st team member call out request/action; 2nd team member checkback request/action, then 2nd team member confirm request fulfilled/action performed.Does NOT use closed-loop communication0Uses closed-loop communication some of the time1Uses closed-loop communication all the time213Contacts providerDoes NOT contact provider0Contacts provider 214Uses SBAR: SituationDoes NOT communicate Situation to provider0Communicates Situation to provider partially1Communicates Situation to provider completely and accurately215Uses SBAR: BackgroundDoes NOT communicate Background to provider0Communicates Background to provider partially1Communicates Background to provider completely andaccurately216Uses SBAR: AssessmentDoes NOT communicate Assessment to provider0Communicates Assessment to provider partially1Communicates Assessment to provider completely and accurately217Uses SBAR: RecommendationsDoes NOT communicate Recommendations to provider0Communicates Recommendations Situation to providerpartially1Communicates Recommendations Situation to providercompletely and accurately218Discusses Interventions with PatientDoes NOT discuss interventions with patient0Discusses interventions with patient partially1Discusses interventions with patient2Implementing orders/interventions19Administers BenadrylDoes NOT administer diphenhydramine0Administers diphenhydramine incorrectly 1Administers diphenhydramine correctly 220Administers ZantacDoes NOT administer cimetidine correctly0Administers cimetidine incorrectly1Administers cimetidine correctly221Re-assesses patient and vital signs throughout simulationDoes NOT re-assess patient and vital signs 0Re-assess patient some of the time1Re-assesses patient and vital signs continually222Administers OxygenDoes NOT administer oxygen correctly 0Administers oxygen correctly2 Highest possible score = 44Total Score:Provider Learner Critical Actions Checklist Competing Team_______________Red in the FaceCritical ActionsCriteriaScore1Sanitizes handsDoes NOT wash/sanitize hands0Some members wash/sanitize hands1All team members wash/sanitize hands22Infection ControlDoes NOT gown and glove before approaching patient0Some members gown and glove before approaching patient (if more than 1 provider learner)1Gowns and gloves before approaching patient23Introduce Self/TeamDoes NOT introduce self/team0Introduces self/team2Reviews History/Physical Assessment4Review History/Vital SignsDoes NOT review history and vital signs0Reviews history or vital signs but not both1Reviews history and vital signs 25Assesses Lung soundsDoes NOT auscultate lungs 0Auscultates anterior lung sounds1Auscultates anterior and posterior lung sounds26Assesses WoundDoes NOT assess wound verbally or physically0Assess wound verbally or physically2Communication and Teamwork7Team LeaderDoes not identify team leader verbally0Identifies team leader verbally28Team Member RolesDoes NOT maintain clearly defined team member roles0Maintains clearly defined team member roles29Uses Closed-Loop Communication Among Healthcare Team: 1st team member call out request/action; 2nd team member checkback request/action, then 2nd team member confirm request fulfillment/action performed.Does NOT use closed-loop communication0Uses closed-loop communication some of the time1Uses closed-loop communication all the time210Uses SBAR: SituationDoes NOT communicate Situation to RN learner0Communicates Situation to RN learner partially1Communicates Situation to RN learner completely and accurately211Uses SBAR: BackgroundDoes NOT communicate Background to RN learner0Communicates Background to RN learner partially1Communicates Background to RN learner completely and accurately212Uses SBAR: AssessmentDoes NOT communicate Assessment to RN learner0Communicates Assessment to RN learner partially1Communicates Assessment to RN learner completely and accurately213Uses SBAR: RecommendationsDoes NOT communicate Recommendations to RN learner 0Communicates Recommendations Situation to RN learner partially1Communicates Recommendations Situation to RN learner completely and accurately214Communicates with Patient Does NOT discuss diagnosis and plan of care with patient0Discusses diagnosis or plan of care with patient, but not both1Discusses diagnosis and plan of care with patient2Provider Learner: Diagnosis/Orders15Diagnose Red Man SyndromeDoes NOT diagnose Red Man Syndrome0Diagnose Red Man Syndrome216Diagnose Red Man SyndromeDoes NOT confirm vancomycin infusion is stopped0Confirms vancomycin infusion is stopped217Orders TreatmentDoes NOT give any orders to RN learner0Orders some but not all of the following: oxygen, diphenhydramine 75mg PO, cimetidine 300mg PO1Orders Oxygen, diphenhydramine 75mg PO, and cimetidine 300mg PO218Enters Orders in Electronic Health RecordDoes NOT enter orders in electronic health record0Enters some but not all orders in electronic health record1Enters all orders in electronic health record2Highest possible score = 34Total Score:Debriefing Plan:In groups, with video and independent peer observersDebriefing MaterialsHow did it feel?What do you think went well?What did you have difficulty with?Is there anything you would have changed/done differently?RulesSafe learning environment -communicate to learners that: they should maintain respect for each other, their questions and concerns will be acknowledged, they will receive honest feedback without being judgedConfidentialityNon-punitiveQuestions to Facilitate the DebriefingWhat antibiotic was the patient receiving?What should the provider observe for when administering vancomycin?What types of hypersensitivities can occur when administering vancomycin? What was this patient experiencing?When does red man syndrome typically occur?Under what conditions does red man syndrome occur?How can the incidence of red man syndrome be prevented?If red man syndrome occurs what is the most important intervention?If red man syndrome occurs what is a pharmacologic intervention?How long should vancomycin be administered over?Can vancomycin be administered after a patient experiences red man syndrome?Answers to Debriefing QuestionsVancomycinHypersensitivities or allergiesRed man syndrome and anaphylaxis (hypersensitivities)Red man syndromeWithin 4-10 minutes of beginning the antibiotic infusion or soon after the completionWhen vancomycin is infused over too short a period of time, less than 60 minutesSlower infusion rate (greater than 60 min) or pretreatment with H1 and H2 receptor blockers (diphenhydramine, cimetidine)Stopping the infusionH1 and H2 receptor blocker(diphenhydramine, cimetidine)1 gram over at least 90 minutes or longerYes. Vancomycin is much better tolerated when it is given in smaller and more frequent doses. In clinical situations where prolonged infusion times are often impractical, as in the intensive care unit or an operative setting, especially ambulatory orthopedic or emergency procedures, pretreatment with antihistamines combined with an H2 receptor blocker can offer protection against this infusion-related reaction. (Sivagnanam et al., 2003)Pilot Testing: This scenario was initially used with nursing students during a simulation competition. The students quickly identified an allergic type reaction and during debriefing discovered the cause of the symptoms they recognized. Approximately 10 nursing students participated in the scenario and an additional 10 observed the scenario in real-time. Responses to a follow-up survey indicated that the scenario was clinically relevant to the nursing student population.This scenario was additionally tested with an interdisciplinary care team, including paramedics and physicians. The pilot test revealed that the scenario was clinically accurate, and the teaching points associated with distinguishing red-man syndrome from anaphylaxis and the appropriate treatment was relevant to a varying group of clinicians. The pilot group thought the scenario would be useful to train medical and nursing students as it is provides a comprehensive acute scenario for an interdisciplinary group to work together to treat, while taking into account their limited knowledge base. References:Sivagnanam, S., Deleu, D. Red Man Syndrome. Critical Care 2003, 7:119-120.Renz, C., Thurn, J., Finn. H. A., Lynch, J. P., Moss. J. Oral antihistamines reduce the side effects from rapid vancomycin infusion. AnestheAnalg 1998, 87:681-685.Bailey, P., Gray, H. An Elderly Woman with “Red Man Syndrome” in association with oral vancomycin therapy: A Case Report. Case Journal 2008, 1:111.Simulation Authors: Jared Kutzin, DNP, MPH, RN, EMTDirector of Simulation, Saint Barnabas Medical Center, Livingston, NJAssistant Professor, Lienhard School of Nursing, Pace University, New York, NYStaff Nurse, Englewood Hospital and Medical Center, Englewood, NJGrace Ng, MS, CNM, RNC-OB, C-EFMNurse Educator, NYU Langone Medical Center, New York, NY ................
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