SIMULATION DESIGN & PLANNING TEMPLATE
Scenario Name
Patient Safety – Sepsis RN Resident
Program/Curriculum Specific Objectives:
Utilize standards for recognizing and responding to sepsis
Measurable Objectives (minimum 2, maximum 10)
1. Recognize signs and symptoms of sepsis
2. Discuss use of Surviving Sepsis Campaign Care Bundle
3. Identify possible source of sepsis
4. Initiate rapid response team
Instructor’s Name Mary Burroughs Shoreline Community College
Karen Paulsen Northwest Hospital & Medical Center
Date Submitted Spring 2013
Will There Be Any Pre-Simulation Lecture?
Expected Scenario Time 15-20 minutes
Expected Debrief Time
No
20-40 minutes
Report and Information Provided To Participants Prior To Simulation
Mr. Simman was admitted 3 days ago with community acquired pneumonia. Shortly
after admission, a urinary catheter was placed for inability to void and BPH. A routine
analysis at that time found bacteria. He has a PICC line in his right arm with IV fluids
NS at 100ml/hr. He is receiving Rocephin every 12 hours, due at 1600. Noon vital
signs were 37.5, 110/60, 80, 18, SpO2 96% on room air. The day nurse has been busy
with an admission and has not seen him since noon.
Patient Information
Patient Name:
Age: 74
Sam Simman
Gender:
Birth date: 4/23/1939
Male
Height:
Weight:
6’0”
105 Kg
ID band MR #00001234 Acct. # 1198765432
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
1
SIMULATION DESIGN & PLANNING TEMPLATE
Hx. Present Illness: Admitted from the ED with pneumonia 2 days ago. Patient is
receiving Rocephin. Foley catheter inserted due to inability to void and BPH.
Social History: Married for 45 years, 3 grown children, not in area. Smoker 1
PPD for 55 years. Drinks rarely. Immigrated from Pakistan 32 years ago.
Religion: Muslim, not practicing
Support System: Spouse, neighbors, Pakistani community
Allergies: PCN, Lipitor
Immunizations: Up to date except pneumonia
vaccine received 6 years ago
Attending Physician: Quinnan
Past medical history: BPH, history multiple UTI, lumbar laminectomy 2004,
appendectomy 1985, COPD
Physical description of how you want the manikin to present at start of scenario?
Moulage:
Add picture here:
In bed with patient gown, clammy, coughing, anxious, (may be tremulous if using
manikin with this capability)
Assignment Of Roles (Please indicate below roles to be assigned):
Primary Nurse
Secondary Nurse
Family Member #1
Unlicensed Assistive Personnel/CNA/MA
Code Team List Members:
Important Information Related To Roles:
The wife is in the room. She is concerned about her husband, he seems more
uncomfortable and anxious. She defers to the husband when he speaks.
SIM Setup
Mannequin
IV site :
3G or Task trainer arm
Site __Right arm_______ Gauge _PICC___
Mist manikin with water
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
2
SIMULATION DESIGN & PLANNING TEMPLATE
Fidelity (choose all that apply to this simulation)
Setting/Environment
ER
Med-Surg
Props:
Equipment attached to manikin:
Primary IV Fluid NS running at 100 ml/hr in PICC line
Secondary IV Fluid running at
ml/hr
Foley catheter 60 ml output; Urine color dark, cloudy
IV pump running
IVPB with Rocephin not infusing
O2
Monitor attached/ Type
ID band
SCD’s on and running
Equipment available in room:
Crash cart c airway devices and emergency meds
Fluids
Incentive Spirometer
IV start kit
IV tubing
IVPB tubing
IV pump
O2 delivery device & nasal cannula
Suction
Defibrillator/Pacer
Other:
Other Props:
Medications and Fluids:
Oral Meds Acetamenophen 325 mg tablets- two
IV Fluids 1000ml Normal Saline IV bag
IVPB Vancomycin 1 gm in 100 ml bag
Diagnostics Available:
Labs Values
X-Rays (Images) - Chest
12 lead EKG
Other: UA
Documentation Forms:
Physician Orders
MAR
Kardex
Graphic Record/ I & O record with decreasing urine
output
Shift Assessment
Code Record
Standing (Protocol) Orders: Sepsis Order Set
Other
Recommended Mode for Simulation
Manual
Programmed
Manual/Programmed Hybrid
Other
Manikin to be used 3G/Essential Manikin # 1
Significant Lab Values
Physician Orders
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
3
SIMULATION DESIGN & PLANNING TEMPLATE
Scenario Progression Outline
Stage 1
Initial Amount
Time in Initial
Stage- 5 mins
Baseline Vital Signs
T PR 38, 115, 26
BP 94/50
SPO2 90% RA
Cardiac Rhythm ST
Breath Sounds
Coarse Crackles
Right upper lobe,
all other lobes clear
Frequent coughing
Heart Sounds WNL
Abdominal Sounds
WNL
Other Symptoms:
Anxious, clammy,
coughing, chills
(tremors). Oriented
to person only.
Verbalization
(Pt/Manikin
Cues)
“I want to get
up. I have a
tee time at the
golf course.”
“Dear, get me
my clothes so
we can leave”
Expected
Interventions
Identify self
(AIDET)
Reassure pt
Assess pt
Assess VS
Note low
SpO2
Note low
urine output
Call MD on
phone, using
SBAR
Alternate or Incorrect
Treatment Choice
That Will Affect Outcome
Confederate
Actions/Additional
Role Player Cues
“He’s been so upset this
afternoon!”
“I know dear, but we
have to stay here”
“Why is he shaking so
much?”
Write on
physician
order sheet
and Repeat
back MD
orders
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
4
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
Stage 2
Timing Sequence
Expected
Receives orders from
Interventions
MD on phone
for UA; chest x-ray;
Ask for antiblood cultures X2;
anxiety or
sputum sample; IV
delirium med,
bolus of 500 ml NS;
MD to provide
change antibiotic to
Ativan 1mg IVP
Vancomycin 1 Gm
every 4 hours prn
every 8 hours; oxygen 2 OR Haldol 0.5mg
liters by nasal cannula;
IVP every 4-6
acetaminophen 650mg
hours prn
po now and q 6 hours.
Start IV bolus
Start oxygen
If nurse does not report Give
urine output, MD to
Acetaminophen
prompt.
Correct Treatment Choice
Stage 3
Timing Sequence
Expected
2 hours later
Interventions
Baseline Vital Signs
Call MD using
T 38.2
SBAR. Orders
P 120
include: IV fluid
R 28
bolus of 250ml
BP 88/48
NS and increase
SPO2 91% on 2 L/NP
main IV to
Cardiac Rhythm ST
150ml/hr; titrate
Breath Sounds
O2 up to 5 liters
unchanged
to maintain SpO2
Heart Sounds WNL
of 95%; give
Abdominal Sounds
Vancomycin now.
WNL
Other Symptoms:
Coughing
Verbalization
Urine output still low
(may add 5 ml)
Alternate or Incorrect Treatment choice
Stage 3A
Timing Sequence
Expected
2 hours later
Interventions
Baseline Vital Signs
Call rapid response
T 38.6
team
P 128
Give rapid infusion
R 18
normal saline
BP 80/40
Increase oxygen
SPO2 89% on 2 L/NP
rate and change to
Cardiac Rhythm ST
mask
Breath Sounds
Anticipate transfer
unchanged
to ICU
Heart Sounds WNL
Abdominal Sounds
WNL
Other Symptoms:
Sleeping
Eyes closed
Occ. Cough
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
5
SIMULATION DESIGN & PLANNING TEMPLATE
Instructor Check List
(return to CHESC assistant at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
6.
7.
8.
Equipment is staged as requested.
The learner has been oriented to the simulator.
The learner understands the guidelines/expectations for the
scenario.
Participants understand their assigned roles.
The time frame Expectations for simulation met: Yes No.
The time frame Expectations for debrief met: Yes No.
Audio/Visual Consent signed and turned into CHESC sheet.
Attendance sheet completed and given to CHESC staff.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
CHESC Assistant Name:
Did the person provide excellent support for the scenario?
Yes
No Comment
Instructor signature ________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
6
SIMULATION DESIGN & PLANNING TEMPLATE
Participant Check List
(return to Instructor at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
I have been oriented to the simulator.
I understand the guidelines/expectations for the scenario.
I understand the assigned role.
My questions about the simulation have been answered.
I have all necessary equipment for the simulation.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Participant Signature ____________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
7
SIMULATION DESIGN & PLANNING TEMPLATE
Simulation Post-Assessment Methods
Checklist
Tests
Evaluations
Turning Point
Jeopardy
Other
Optional Literature References
American Association of Critical Care Nurses. (2010). AACN practice alert: Severe sepsis: Initial
recognition and resuscitation. Retrieved from
http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Severe%20Sepsis.pdf
Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med 2013; 41:580-637.
Hughes, R. G., (Eds.). (2008). Patient safety and quality: An evidence-based handbook for nurses.
Rockville, MD: Agency for Healthcare Research and Quality.
The Joint Commission. (2013). National patient safety goals effective January 1, 2013. Retrieved
from http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf
Institute for Healthcare Improvement. (2013). SBAR technique for communication: A situational
briefing model. Retrieved from
http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefin
gModel.aspx
Debriefing Guidelines
(Remember to identify important concepts or curricular threads that are specific to your
program)
1. Leave the simulation room and go to a conference room, if possible. It allows for deescalation of emotions.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
8
SIMULATION DESIGN & PLANNING TEMPLATE
2. Solicit and validate emotions briefly. Validate simisms (the simulation isn’t 100% accurate
due to different equipment, personnel etc)
3. What went WELL in this simulation?
4. What DID NOT go well in this simulation?
5. If you could do it again, what would you do differently?
6. Summarize:
“What I hear you saying is . . .”
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
9
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
10
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
11
SIMULATION DESIGN & PLANNING TEMPLATE
Lactic Acid
(0.5 - 2.2) mmol/L
.
4.2
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
12
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
13
SIMULATION DESIGN & PLANNING TEMPLATE
Color Ur
(Yellow)
Amber
Appearance Ur
(Clear)
Cloudy
Specific Gravity
(<=1.005 - >=1.030)
<=1.025
pH Urine
(5.0 - 8.0)
7.5
Protein Qual Ur
(Negative)
Negative
Glucose Qual Ur
(0) mg/dL
Negative
Ketones Ur
(0) mg/dL
Negative
Bilirubin Ur
(Negative)
Negative
Blood Ur
(Negative)
Moderate A
Leukocytes Ester...
(Negative)
Large A
Nitrites Ur
(Negative)
Negative
UA Microscopic E...
WBC UR
Performed
(0-5)/HPF
Packed field
Epithelial Cells UR (1+)/HPF
2+
Bacterial UR
4+
Culture and Sens...
(Occasional)/HPF
Yes
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
14
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
15
SIMULATION DESIGN & PLANNING TEMPLATE
Prothrombin Time
(8.9 - 12.1) sec
10.5
INR
(0.7 - 1.3)
1.2
Partial Thrombop...
(24.9 - 36.1) sec
Sodium
(133 - 145) mEq/L
137
Potassium
(3.1 - 5.1) mEq/L
4.9
Chloride (CL)
(97 - 108) mEq/L
99
CO2
(21 - 33) mEq/L
Anion Gap
(5 - 17) mEq/L
Glucose
(60 - 99) mg/dL
110
Blood Urea Nitro...
(5 - 23) mg/dL
40
Creatinine
(0.60 - 1.50) mg/dL
1.9
Est. Glom. Filt....
(>59) ml/min/1.73 m2
Calcium
(8.3 - 10.2) mg/dL
Phosphorus
(2.8 - 5.1) mg/dL
Magnesium (Mg)
(1.9 - 2.5) mg/dL
2.0
Ionized Calcium
(1.13 - 1.32) mmol/L
1.08
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
16
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
17
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
18