1. Recipe for Interdisciplinary Emergency Training in the Ambulatory Setting Beth Anne Fox, MD, MPH; Douglas Rose, MD; Brian Cross, PharmD, BCACP, CDE; Martin Eason, MD, JD; Quillen Colleges of Medicine and Pharmacy East Tennessee State University

2. Faculty Disclosure The Faculty have nothing to disclose…

3. Learning Objectives 1.Discuss current emergency training programs and recognize practice needs and deficiencies to improve patient safety and improve educational and patient outcomes in ambulatory emergency management 2.Recognize and plan for interdisciplinary needs of home institutions in managing ambulatory emergencies 3.Describe the elements of one method of an interdisciplinary outpatient emergency care curriculum

4. Background IOM report on patient safety PCMH and attention to patient safety Required ambulatory emergency training Questioned sustainability of prior training Focus on team care and management

5. Our Process/Template Common emergencies identified Mock simulation emergency with debriefing Deficiencies identified Team members identified Interdisciplinary group brainstorming Didactic sessions for all team members with responsibilities Checklists and protocols written for identified objectives Repeat mock simulation emergency with debriefing

6. Identify Ambulatory Emergencies Anaphylaxis Others ? Practice setting Patient demographics Current training

8. Assessment of Current Emergency Protocols VIDEO of simulation unavailable

9. Needs Identified Prior emergency training not sustained Confusion / Lack of coordination Leadership Communication errors Unfamiliarity with supplies Inadequate clinical skills Medication mismanagement Delay in accessing EMS

10. Debriefing/Brainstorming Identification of team members Primary roles/responsibilities Secondary roles/responsibilities Member-specific didactics Written protocols and policies Process improvement Equipment/supply needs

11. Team Members Front office staff Patient care specialists Pharmacy Behavioral health Providers –Medical students –Residents –Faculty

12. Educational Didactics Activation of EMS Roles and responsibilities Location of supplies Oxygen Code cart ECG IV supplies Anaphylaxis management Communication skills Written protocol/checklists

13. Team Skills http://teamstepps.ahrq.gov

14. Team Process Objectives: Planning/Preparation –Mission Analysis –Goal Specification –Strategy Formulation Action: –Monitoring Progress –Systems Monitoring –Coordination Mechanisms: –Communication –Leadership

15. Emergency Scenario Development Scenario Objectives –Clinical Objectives/ACGME competencies Team Process Objectives Systems Objectives Scenario preparation

16. Anaphylaxis Emergency Training Scenario Scenario Learning Objectives: a. Team assembles and performs rapid assessment of pediatric patient with acute shortness of breath through acquisition of history and physical examination b. Recognize the signs and symptoms consistent with anaphylaxis c. Institute appropriate evidence based management of anaphylaxis Team Process Objectives: A.Planning/Preparation a.Team communicates probable diagnosis b.Team prioritizes and reprioritizes activities as needed c.Team communicates plan to address problem identified B.Action a.Team acknowledges and communicates completion of tasks b.Availability of resources is reported among team members c.History and physical examination occurs in coordinated fashion C.Mechanisms a.Closed loop communication is used between team members b.Roles are assigned and modified as needed to accomplish goals System Objectives: a. Activation of EMS/call 911 b. Requires involvement of non-physician team members c. Requires location and use of necessary equipment by ancillary staff-secondary functioning

17. Debriefing Occurs after event by responders Use video for key points if available Allow for reflective learning Always make it a positive experience Review roles, responsibilities, tasks, and achievement of patient stabilization Validate participants’ observations Summarize learning points

18. Your Curriculum? Next Steps…… Small groups Identify an emergency in your practice Implementation barriers Teaching Goals? Cognitive skills Decision making Procedural competence Crisis management –Role clarity –Asset management –Thinking outside the box –Communication –Resources usage Professionalism

19. Data Review Emergency Procedures Task Assignments

20. Simulation #1 Emergency Procedures Questiontp Pre- Intervention Mean Post-Intervention Mean 12. I can locate the peripheral intravenous tray -2.71p <.012.503.50 19. I can determine the location of an emergency in the clinic from our emergency alarm system -2.81p <.012.753.58

21. Simulation #2 Emergency Procedures Questiontp Pre-Intervention Mean Post-Intervention Mean 1. Identify an emergency patient situation -2.73p <.053.784.00 4. Determine if a patient is without a pulse -2.43p <.053.814.00 15. Locate the electrocardiogram machine -2.06p <.053.563.90 16. Locate the oxygen saturation monitor -2.29p <.053.303.80 21. Determine the location of an emergency in the clinic from our emergency alarm system -2.49p <.053.483.90

22. Simulation #2 Task Assignments Questiontp Pre-Intervention Mean Post-Intervention Mean 2. Activate the community EMS personnel -2.49p <.055.046.00 5. Locate the oxygen tank and supplies -2.48p <.054.395.60 8. Bring the crash cart to the emergency scene -2.69p <.055.006.00 14. Document clinical assessments and therapeutic interventions -2.22p <.052.914.00 20. Alert the emergency room of anticipated patient arrival -3.04p <.013.265.10

23. Curriculum Template Common emergencies selected Mock simulation emergency with debriefing Deficiencies identified Team members identified Interdisciplinary group brainstorming Didactic sessions for all team members with responsibilities Checklists and protocols written for identified objectives Repeat mock simulation emergency with debriefing

24. Clinical and Therapeutic Challenges Medical knowledge deficit Medication Protocol Changing team members Supplies not available Unfamiliarity with supplies Inadequate procedural skills

25. Process and System Challenges Prior emergency training not sustained Confusion / Lack of coordination Leadership Communication errors Delay in accessing EMS

26. Successes Proper equipment and supplies Written protocols Identified roles (primary and secondary) Perceived improved emergency management Template for ongoing emergency training

27. Summary 1.Emergency training can be improved if you can identify process and system deficiencies 2.Plan for ambulatory emergencies by identifying and recognizing interdisciplinary team needs 3.This template can be used to create training scenarios for ambulatory emergencies and improve team performance and provide process and system improvements

28. References 1.Institute of Medicine: To err is human: building a safer health system. Washington, DC: National Academies Press; 1999. 2.Crossing the quality chasm – a new health system for the 21 st century. Washington, DC: National Academies Press; 2001. 3.2012 National safety goals. Oakbrook Terrace, IL: Joint Commission; 2012. Available at: www.jointcommission.org/PatientSafety/NationalSafetyGoals.htm. Accessed May 30, 2012.www.jointcommission.org/PatientSafety/NationalSafetyGoals.htm 4.Training requirements for OSHA standards and training guidelines. US Department of Occupational Safety and Health Administration; 1998. Available at: www.osha.gov/Publications/osha2254.pdf. Accessed May 30, 2012. www.osha.gov/Publications/osha2254.pdf. 5.Pennsylvania Patient Safety Authority. “Clinical emergency: are you ready in any setting?” Pa Patient Saf Advis. 2010; Jun ; 7(2):52-60. 6.Brooks-Buza H, Fernandez R, and Stenger JP. The use of in situ simulation to evaluate teamwork and system organization during a pediatric dental clinic emergency. “Sim Healthcare. 2011; 6: 101-108.

29. References 7.Webster JS, King HB, Toomey LM, et al. Understanding quality and safety problems in the ambulatory environment: seeking improvement with promising teamwork tools and strategies. In: Henrikson K, Battles JB, Keyes MA, et al, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US): 2008 Aug. 8.Bridges DR, Davidson RA, Odegard PS, et al. “interprofessional collaboration: three best practice models of interprofessional education.” Medical Education Online. 2011; 16: 6035 - DOI: 10.3042/meo.v1610.6035. 9.U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. TeamStepps. http://teamstepps.ahrq.gov. Updated November 2013. Accessed November 1, 2013.http://teamstepps.ahrq.gov 10.U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Patient-centered medical home. http://pcmh.ahrq.gov. June 2010. Accessed November 1, 2013.http://pcmh.ahrq.gov

30. Contact Information foxba@etsu.edu rosed@etsu.edu crossl@etsu.edu eason@etsu.edu