1. Simulation Project: Gap Day
Nursing Orientation: Emergency Department
Shannon Gaines BSN, MSNc, RN, CPEN

2. Needs Assessment Survey Monkey Change to orientation
New documentation system
August 2013 Survey Monkey was created to evaluate effectiveness of current orientation, and additional needs from the perspective of the orientee
need identified: trauma room exposure
-problems:
unpredictable nature of traumas
large number of orientees on at the same time
need to balance orientee and experienced RN assigned to trauma room roles
Change to orientation:
original orientation plan: new graduate nurse to have 16 week orientation—changed to 12 week hrs/week (approximately same amount of time in less # of weeks)
Launching new documentation system: “trauma narrator” in EPIC
CREATES LEARNER BUY IN

3. Trauma room nursing roles and responsibilities
EPIC Narrator documentation
The goal of this simulation experience is to introduce the nursing orientee to the trauma room nursing roles and responsibilities as well as EPIC Narrator documentation

4. Learners Identified Inclusion Criteria: Emergency Department RN
Currently on orientation
New graduate
Experienced nurse
Gap Day 1 complete
Any nurse on orientation from June 2014 to September 2014

5. Gap Day Emergency Department Nursing specific Learning Days
Standardize critical needs education for the orientee
Assess learner needs not met by preceptor
Divided into 2 days
Early orientation
Near end orientation

6. Gap Day 1 Early orientation Review documentation standards
Review critical care skills
Simple Simulation with airway management

7. Gap Day 2 Late/end orientation Simulation immersive
Assess critical thinking
Assess learner ability “completion” orientation

8. Pre-work- Day 2 Trauma Narrator PowerPoint
EPIC Sandbox practice documentation
Trauma Activation Roles Job Aid
These documents were provided as support to the orientee.
Roles/documentation standards are expected to be reviewed with preceptors prior to the end of orientation.

9. Learning Objectives
By the completion of the simulated experience, the nursing orientee will be able to:
Differentiate the trauma room nursing roles and responsibilities as per the Trauma Room Roles Job Aid.
Practice trauma documentation standards as per the Trauma Room Roles Job Aid via EPIC Trauma Narrator.
Execute the appropriate nursing actions (skills) for each trauma room nursing role.
Anticipate the role and actions of each trauma nursing role.
(The Children’s Hospital of Philadelphia, 2012)

10. Simulation Design Rapid Cycle Deliberate Practice
Maximize time in deliberate practice
Practice skills learned immediately
Development of muscle memory
(Hunt, et al., 2013)
15 minutes designated for each “role”
5-10 minutes in deliberate practice
5 minutes to debrief
5-10 minutes to debrief overall simulation
Extract skills acquisition from participants

11. Case Presentation
15 y.o. male in an ATV accident with (+) LOC, current GCS 15. Patient will have mental status compensation as well as hemodynamic compensation. Ecchymosis to lower back with log roll. Inappropriate c-collar size, patient will require intubation R/T head trauma and IVF and pressors for hemodynamics.

12. Critical Actions Bedside Nurse Remove clothing
Place patient on CR monitor
Set BP to cycle every 3 minutes
Assess patient temperature
Set up and administer push pull fluids when ordered
Obtain IV access
Identify appropriate lab tubes for trauma labs
Appropriately label specimens
Appropriately perform log roll when asked by MD lead
Identify inappropriate sizing of C-collar
Change c-collar to appropriate size
Maintain c-spine immobilization
Performs read-back with medication nurse
Utilize closed loop communication with MD lead and documenting
Based upon job aid- handout provided to audience

13. Critical Actions Documentor
Start trauma by clicking “start trauma” as patient enters the room
Enable Dosing weight
Assign provider
Document appropriate primary and secondary survey
Vitals documented every 3 minutes
Verbalize need for further assessment if not available (i.e. vitals, primary, secondary survey, reassessment of abnormalities)
Document when medications are given
Document Intake and Output
Document interventions performed (warmed room, warmed blankets, IV, NG, ETT, etc.)
Document “trauma end”
Document transfer
(The Children’s Hospital of Philadelphia, 2014)

14. Evaluation Tool
Observer Checklist

15. Documenter Checklist

16. Evaluation Learning Occurred Difficulty debriefing EPIC Narrator
Timing limitation
Significant manpower needed
Number of participants
This will be discussed further on the next slide
Focus was drawn to the mannequin and the actions of the bedside nurse.
Limited reflection to EPIC as it is difficult for both the bedside nurses and the facilitator to view what is being documented.
Timing for debriefing was limited
Time frame set 50 minutes
To allow time for reflection more time Is necessary
2 confederates, 2 observers, facilitator, operator
Three participants worked well for the simulation, allowed for rotation without running the simulation for too long

17. Evaluation of Learning
Comfort with trauma room roles
Improved timing of critical needs
1st 5-minute interventions
Monitor
Clothing
Trauma management
Log roll
IV insertion
Labs
Bolus administration
Review of documentation with EPIC Narrator
Trauma documentation standards
Vitals every 3-5 minutes
Initial GCS/trauma scores
Enabling dosing weight
Assigning attending provider
Participants showed increased comfort and knowledge of tasks for each role.
Each rotation participants built upon what they had been debriefed upon. For example: rapid sequence intubation medications and contraindications.
Monitor time difference 2 minutes and 15 seconds to 1.5 minutes to 1 minute 10 seconds
Clothing 1.5 minutes to 20 seconds to 10 seconds
Discussed trauma management, participants
reflected on importance of:
Early log roll,
IV insertion and bore selection
What labs are drawn- what information can they give us
Methods of fluid administration, push pull, pressure bag, rapid infuser.

18. Participant Evaluations
Overall Positive evaluation
Likhert scale survey given
Survey Results
Participants agreed that objectives were met
What was most helpful in this simulation
“becoming more comfortable with my own knowledge”
“Learning roles and practicing skills”
“the discussion, and continuing the scenario after discussing”
What would you have done differently?
“a lot at one time”
Survey was given to evaluate learner perception of:
Learning objectives met
If discussed topics were essential to learning needs
Areas for improvement
What was helpful

19. Future Considerations
Is the simulation reproducible?
Number of participants
Ancillary staff requirement
2 confederate roles
2 observers
Develop two separate simulations
Trauma: Bedside Nurse
Trauma: Documentation

21. References
Hunt, E., Duval-Arnold, J., Nelson-McMillan, K., Bradshaw, J., Diener-West, M., Perretta, J., and Shilkofski, N. (2013). Pediatric resident resuscitation skills improve after “Rapid Cylce Deliberate Practice” training. Resuscitation. 85(7).
The Children’s Hospital of Philadelphia. (2012) Job aid SIM-4001C: Writing educational objectives. Accessed via employee intranet.
The Children’s Hospital of Philadelphia. (2014). Job Aid: Trauma Activation Roles. Accessed via employee intranet.