1. Oncology experience of simulation Alan Christie Consultant medical oncologist

2. Background Significant event on ward 3 last year Multiple learning points raised during subsequent investigation, including: Potential signs of this deterioration were missed Lack of escalation from nursing staff/junior medical staff

3. Actions In response, we wanted to test our escalation policies Previous engagement with simulation team for a neutropenic sepsis scenario Discussed setting up an upper GI haemorrhage simulation on one of our wards Aims: Observe our team working in a high pressure situation Test our escalation policies

4. What we did Ward 4 chosen for exercise Charge nurse aware of scenario and objectives Staff nurses aware a simulation was to be run during their shift, but not the nature or objectives of this Medical staff (except myself and Dr Dawson) unaware of simulation Anyone called into room to assist informed of simulation as they entered

5. Preparation SimMan arrived in side room on ward 4 Double room chosen to allow extra space BTS involved in setup Patient details chosen to match pre-prepared blood products Aware to expect call ICU made aware of simulation exercise running Dr Dawson masquerading as GI or surgical middle grade Participants made aware to start calls with ‘this is a simulation’

6. Objectives of simulation 1.The lead of the responding team makes a clinical diagnosis of a major haemorrhage in a deteriorating patient with earlier signs of a small GI bleed 2.The team has initiated the major haemorrhage protocol (MHP) within 5 minutes of being called to urgently review the patient 3.Blood arrives on the ward within 5 minutes of the MHP being activated 4.The nursing team adhere to the escalation policy to get help and the senior Registrar is contacted and informed of the patient within 15 minutes of the initial presentation 5.Senior medical advice confirms the need of an urgent upper GI endoscopy and a call is made to the GI registrar within 30 minutes 6.A minimum of two units are transfused within 30 minutes

7. What happened Exercise started 11.50am Nurse called to SimMan by sounding patient call button Ward FY1 called in to assist within 5 minutes FY2 asked to assist, left after FY1 said they felt in control of situation Major haemorrhage protocol activated within 7 minutes Blood products on ward within 12 minutes ICU contacted and outreach team on ward within 20 minutes

8. Problems identified Scenario ran for 30 minutes No senior oncology input arrived within this time Failure to escalate scenario in first 20 minutes After prompting: Attempts to page oncology registrar on call – no response to page Attempts to phone oncology registrar on call – call fielded by triage nurse Attempts to call Dr Dawson (simulated patient’s consultant) Switchboard refused to connect

9. Problems identified Acutely deteriorating patient recognised but emergency buzzer not activated Blood requested and arrived quickly but delivered through narrow bore giving sets That the team still managed to deliver 3 units red cells in 30 minutes reinforces robustness of MHP While initial response and continued assessment of patient was performed very well, no thought of ‘what next?’ GI registrar not contacted until oncology registrar arrived on ward

10. Achievement of objectives 1.The lead of the responding team makes a clinical diagnosis of a major haemorrhage in a deteriorating patient with earlier signs of a small GI bleed 2.The team has initiated the major haemorrhage protocol (MHP) within 5 minutes of being called to urgently review the patient 3.Blood arrives on the ward within 5 minutes of the MHP being activated 4.The nursing team adhere to the escalation policy to get help and the senior Registrar is contacted and informed of the patient within 15 minutes of the initial presentation 5.Senior medical advice confirms the need of an urgent upper GI endoscopy and a call is made to the GI registrar within 30 minutes 6.A minimum of two units are transfused within 30 minutes

11. Escalation in oncology Logistical issues identified Oncology triage team held on call phone from 9am – 1pm (now 9am – 5pm) On call registrar in clinic initially On call registrar in radiotherapy planning during simulation Communications black hole! Unclear responsibilities for acutely deteriorating patients Team registrar / on call registrar / team consultant Frequent off-site working for oncology registrars and consultants

12. Escalation in oncology New policy created on back of this simulation Posters outlining this protocol on every ward New emergency contact pagers for ward doctors and on call registrar Requirement that a registrar passes on emergency page if they have to attend radiotherapy department No other clinical commitments 9am – 5pm for on call registrar

13. Simulation strengths Safe environment to robustly test protocols and how our team functions Realistic Opportunity for debriefing following scenario facilitates learning Specific areas for improvement could be identified within 30 minutes Provide evidence to support changes in practice/protocols

14. Simulation weaknesses As realistic as the scenario was, it is still a simulation and behaviour may not accurately reflect what would happen FY2 being told her help wasn’t required Slow escalation to middle grade doctors Passing middle grades/consultants not asked for help Stressful situation for junior doctors/nurses

15. Acknowledgements Leanne Whyte Jackie Brown Audrey Campbell Gordon Mills Dr Lesley Dawson Dr Jeremy Morton Dr Vicky Tallentire Stephen Hartley Jane Oldham Jon Falconer