Southwestern Virginia’s
Regional Clinical Simulation Centers
If I only knew then what I know now…
Presented by:
Cynthia G. Cunningham, MSN, RN
June 8, 2005
State Council of Higher Education in Virginia
(SCHEV) and regional nursing programs met to
explore ways of partnering with public and
private entities to:
Maximize the use of scarce resources
Address the shortage of nursing faculty
Explore alternatives for nursing student clinical
education
THE PARTNERSHIP
Collaboration of nursing
educators to develop strategies to address the shortage
Radford University
Jefferson College of Health Sciences
Wytheville Community College
New River Community College
Virginia Western Community College
Patrick Henry Community College
RU SON ASSUMED LEADERSHIP
Developed the CSC concept
Submitting CSC proposal to SCHEV
Proposal was included in the Governor’s
Budget for the next biennium
Funding for the project was allocated to
Radford University in July 2006

OVERALL GOAL OF THE CSC
To alleviate the shortage of nurses in
Virginia by increasing the capacity of
nursing schools to enroll students,
maximizing use of faculty resources, and
decreasing competition for scarce clinical
sites
VISION
The Clinical Simulation Center’s will
provide a hands-on learning experience in
an environment that is safe and realistic,
producing quality nurses with enhanced
critical thinking abilities, communication
skills and collaboration experience
THE BUSINESS PLAN


History
Profile
Business Summary
 Product/Services
 Industry Analysis
 Marketing Analysis
 Organization/Management


Financial Section
Assumptions
 Revenue Streams
 CSC Budgetary
Projections

Personnel
 Operating


Equipment Lists
The renovation
SIMmares
Definition:
Simulation based “disturbing” dreams. Typically
occurring between 3am - 5am. Occasionally may
happen during the day.
Renovation/Space Planning Team
CSC Director
Facilities
Planning and
Construction
Laerdal Sales
Rep
Education Management
Solutions (EMS) Hardware
Design Specialist
Create-a-lab
Rep
SIMmare #1
My renovation team is gone
and I don’t know what I am
doing….
Renovation team turn over…...
Laerdal rep decided to change territories
•
•
Wanted to move back to Texas …………
Education Management Solutions (EMS) rep decided
traveling was not conducive to a personnel life!
•
•
Was married within a year
Create-a-lab rep decided to start a family
•
•
Had a bouncing baby boy
Do you think it could be me?!!!!
If I knew then what I know now
I would have an exit review with
any renovation team member leaving
the project.
 I would visit more SimCenters and
ask more questions r/t design
 I would participate in more SUN’s

And if necessary ………….
I live on the Lake and have a boat and SeaDoo…
Great for entertaining
…..boating…..fishing……relaxing...
I have two Newfoundlands
……..and they are great with children
Due renovation team turn-over
I ASSuME’d and my new
team members ASSuME’d
SIMmare #2
The control room
CONNECTIVITY
If I knew then what I know now
I would have clear operational expectations
– central control room separate from SIMroom
with A/V observation
 I would include IT in the renovation team
 I would include – SimPhones to connect each
SimRoom to each control
room operating station

My SIMteam
RU SON
CSC Director
(MSN)
RHEC
Site
RU West
Site
2 MSN’s, 1 IT Specialist
1 Admin Specialist II
VWCC
PHCC
JCHS
2 MSN’s, 1 IT Specialist
1 Admin Specialist II
RU
WCC
NRCC
RU
SIMmare #4
Receiving and Installing 1.9
Million Dollars of Equipment
Of course spending was not the nightmare….
Receiving, installing and tagging all items > $5000 and
all IT equipment was!
Receiving Equipment - Laerdal
Humm
Include “onsite delivery
& installation”
in purchasing
agreement
This
doesn't
look good
Sturgis
DREAMS:
Russell returns
to Virginia
Laerdal representative after receiving equipment
– manikins, room furnishings, task trainers, virtual IV……
Installing Equipment
Room set-ups per site:








1 Med/Surg SimRoom
1 ICU SimRoom
1OB SimRoom
1 Pediatric SimRoom
2 Exam Rooms
1 Multipurpose classroom
with 3-5 patient beds
Simulation Apartment
Computer Classroom
Manikin Assembly:









4 SimMan
4 SimBaby
2 Nursing & 2 ALS Anne’s
2 MegaCode & 2 Nursing Kelly’s
2 Nursing & 2 MegaCode Kid’s
2 Nursing Baby
2 Noelle
4 Adult & 2 Peds Virtual IV,
…….
Installing Equipment - Laerdal
SimMan, try
to behave
yourself
Ouch!
SimMan
kicked me!
Sturgis
DREAMING:
My new
territory
…TEXAS!
Laerdal representative after installation of
equipment
Installing A/V & IT equipment
Room set-up x 7 per site:





2 Pan Tilt Zoom Cameras
Microphone
Cabling between room and
control room to connect (cat 5,
extender boxes)
Cabling between room and
server room (A/V connections)
Cabling between control room
and server room
Server Room:







2 DVR’s
2 computers to control DVR
1 computer to manage video
1 SQL server (database)
1 IIS server (web)
1 Quantum Tape Library
1 SNAP Server for video
storage
Installing A/V & IT equipment
If I knew then what I know now
I would hire 1 IT specialist and 5 MSNs:
 Rationale for one IT specialist:




A bored IT leads to a gone IT
Most everything can be fixed remotely
Standardization between sites
Rationale for Additional MSN:



Increased capacity of student’s served (450 students/semester)
Increased volume of scenarios produced
Back-up for staffing due to illness/surgery, time off….
SIMmare #5
Manikin responses are not in
sync with monitor readings or
scenario program
Another CONNECTIVITY Problem
Nine Pin Problem
PROBLEM:
 Cable extender box –
nine pin connection –
transmission delays
between control room
and manikin.
Manikin pulses and heart rate did
not correlate with programmed
settings and monitor waveforms
(EKG, Pulse…)
SOLUTION:

Pull nine-pin cable through
wall/ceiling and directly
connect to laptop, i.e., by
passing the rose boxes.
If I knew then what I know now
I would request that integrating equipment
be tested with the manikin system prior to
purchase or include a contingency plan for
beta testing in the purchasing agreement
Imagine:
No Monitors
Imagine:
No plan to
connect
manikin to
the Laptop
CONTROL ROOM
MED/SURG ROOM
OB ROOM
PEDIATRIC ROOM
INTENSIVE CARE ROOM
DEBRIEFING ROOM
Lessons Learned Over TIME
Scenario Development

Student driven

Organization
Revenue Planning

Student Preparation & Evaluation


Partnering/Bartering
Admission ticket
Incorporate pre/post encounter
evaluation and add NCLEX ? to pre

Organized Debriefing


Start early…
Reinforce concepts/nursing process
included in “admission ticket”, preencounter, and scenario
Incorporate NCLEX ?s
Partner and/or barter with as many
organizations as possible
Scheduling

Charge fee for unused time

Block scheduling
Curriculum Integration
Orientation
 Boot-camps

 Fundamental
 Front-loading

Standardized patient encounters
 Mental
health
 Assessment, H&P

Follow course syllabus when choosing
scenario
Consider fidelity




Choose the “right” manikin/SP for the
simulation
If equipment is needed actually use the
equipment – headwall O2/suctioning, IV
pump, 12-lead….
Include supporting documentation –
SIMChart
Suspend disbelief – do not ask students to
“pretend” or use phrases like “if you were
taking care of a real patient….you
would…..
Student Driven NOT Operator Driven


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Student intervention or non-intervention
dictates manikin action
All vocals are pre-recorded
Use handlers for all actions that are not
tied to time or sequencing
If sequencing is important, incorporate
standardized cues (vocal, manikin action)
Scenario
Development
Lessons
Learned Process
SCENARIO DEVELOPMENT & REVIEW & STORAGE
Standardized event menus
 Indicate events with v. if vocal is attached
 Lab reports, xrays,…as pdf files to display on
pt. monitor
 Scenarios reviewed & revised every summer
to insure best practice

Scenario
Storage
Lessons Learned
SCENARIO DEVELOPMENT & REVIEW & STORAGE
Shared scenario storage system
 “FinalSim” houses all up-dated scenarios
- batch file runs every night to load to
Laerdal computers

Preparation-Evaluation-Debriefing
Lessons Learned
Putting it all Together
Assessing Preparedness

Need better criteria to assess
preparedness.
Solutions to Assessing Preparedness

Data Collection

Too much information in post
encounter evaluation
Solutions to Data Collection

The bigger picture

Information is fragmented –
inconsistent flow from prep work
through post encounter evaluation.
All scenarios have an admission ticket –
student must complete the admission
ticket to participate in the simulation
Incorporate a pre-encounter and postencounter student questionnaires
Solution to making a bigger impact


Incorporate nursing process in pre/post
encounter evaluation
Incorporate NCLEX question in preencounter and into debriefing
Scenario: CHF
Patient: Willie Morrison Gender: Female Age: 86 Weight: 44.5 kg Height: 152.4 com
Expected Simulation Run Time: 30 minutes
Location: PCU
Simulation Learning Objectives:
Name:
Date:
Instructor:
1. Utilize patient laboratory results and assessment findings to guide medication administration.
2. Insert foley catheter utilizing aseptic technique.
3. Utilize nursing measures and physician orders to maximize gas exchange and decrease cardiac workload .
4. Conduct focused assessment pertinent for patient with CHF.
Patient Information: Increasing shortness of breath and muscular weakness over the past week with non-productive cough and chest pain.
Past Medical History: Atrial fibrillation, congestive heart failure, non-insulin dependent diabetes mellitus, osteoporosis, vitamin D deficiency, hyperlipidemia,
hypertension
Allergies: angiotensin converting enzyme inhibitors
Social History Widow; retired elementary school teacher; no history of alcohol or tobacco use; one daughter lives next door and is her primary caretaker
Surgeries/Procedures: Open reduction and internal fixation of right hip fracture 5 years ago; bilateral cataract extractions with intraocular lens placement;
vertebroplasty
Please review the following PRIOR to your simulation experience:
Intravenous potassium and lasix, PO lanoxin, coumadin, fosamax, calcium, vytorin, glyburide, lopressor, imdur, ASA, regular insulin
Possible skills: foley catheter insertion, use of infusion pump
Pathophysiology of atrial fibrillation, congestive heart failure, type 2 diabetes, osteoporosis
Focused assessments pertinent to diagnoses
Questions to Answer Prior to Simulation Session (Please staple answers to the questions below to this ticket for admission to simulation session. Without this
ticket and completed questions you will not be allowed to participate in the scheduled scenarios). The completed questions will be turned in and checked by
your class instructor.
1. List the 2 most important care priorities for a patient with congestive heart failure?
2. What are the clinical manifestations of hypokalemia?
3. What is the target/goal PT/INR for a patient on Coumadin for atrial fibrillation?
4. Describe the differences in presentation/symptomatology between a patient with left–sided vs. right-sided heart failure.
Ancheta, I. (2006). A Retrospective Pilot Study: Management of Patients with Heart Failure. Dimensions of Critical Care Nursing, 25(5), 220-233.
Deglin, J., & Vallerand, A. (Eds.). (2007, April 19). Potassium Supplements [Electronic version]. In Davis's Drug Guide for Nurses. Retrieved from STAT!Ref Online Electronic
Medical Library: http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=846&FxId=58&S
Hilton, P. (Ed.). (2004). Fundamental Nursing Skills. Philadelphia: Whurr
Kozier, B., Erb, G., Berman, A., & Snyder, S. (2002). Techniques in Clinical Nursing: Basic to Intermediate Skills (5th). Upper Saddle River, New Jersey: Prentice Hall.
Skidmore-Roth, L. (2004). 2004 Mosby's Nursing Drug Reference. St. Louis: Mosby.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (11th ed.). Philadelphia: Lippincott, Williams, & Wilkins
.Sole, M., Klein, D., & Moseley, M. (2005). Introduction to Critical Care Nursing (4th Ed.). St. Louis: Elsevier.]
Hypokalemia-New Treatments. (May 2, 2007). Retrieved September 16, 2007, from Library of the National Medical Society: http://www.medical-library.org/journals2a/hypokalemia.htm
Debriefing
Lessons
Learned
Student driven
 Incorporate admission ticket
questions, pre-encounter into
discussion
 Video review
 NCLEX question review

1. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of
warfarin (Coumadin) 2.5 mg. The serum international normalized ratio (INR) is 4.7.
What intervention should the nurse be prepared to initiate?
1.
2.
3.
4.
Observe the client for a possibility of an embolic
event.
Have a partial prothrombin time (PTT) drawn to
completely evaluate the level of anticoagulation.
Prepare to administer protamine sulfate.
Monitor the client for signs of bleeding.
1. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of
warfarin (Coumadin) 2.5 mg. The serum international normalized ratio (INR) is 4.7.
What intervention should the nurse be prepared to initiate?
1.
Incorrect. If the client were at risk for an embolism, the INR would be very low,
reflecting inadequate anticoagulation.
2.
Incorrect. PTT evaluates anticoagulation levels as a result of heparin, not warfarin.
3.
Incorrect. Protamine sulfate is the antidote for heparin, not warfarin.
4.
Correct. The level of anticoagulation, as reflected by the INR, is too high and the
client is at risk for bleeding. The serum INR is done to reflect the effectiveness of oral
anticoagulants, especially warfarin. The normal value is 2.0-3.0 for clients on
anticoagulation therapy.
Test-Taking Tip: Because the drug is a anticoagulant, choose the “assessment” type of answer
for the one most related to anticoagulant therapy. Eliminate answers 2 and 3 since r/t
heparin.
Evaluation
Lessons
Learned
RAGE
Nursing Process Driven
 Medication error reporting
 Curriculum integration questions

Any questions?