If I only knew then what I know now

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Southwestern Virginias Regional Clinical
Simulation Centers

• If I only knew then what I know now
• Presented by
• Cynthia G. Cunningham, MSN, RN

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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

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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

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RU SON ASSUMED LEADERSHIP

• Developed the CSC concept
• Submitting CSC proposal to SCHEV
• Proposal was included in the Governors Budget
  for the next biennium
• Funding for the project was allocated to Radford
  University in July 2006

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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

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VISION

• The Clinical Simulation Centers 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

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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

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SIMmares
The renovation
Definition Simulation based disturbing
dreams. Typically occurring between 3am - 5am.
Occasionally may happen during the day.
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Renovation/Space Planning Team
CSC Director
Facilities Planning and Construction
Laerdal Sales Rep
Education Management Solutions (EMS) Hardware
Design Specialist
Create-a-lab Rep
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SIMmare 1

• My renovation team is gone and I dont know what
  I am doing.

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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?!!!!
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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 SUNs

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And if necessary .
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I live on the Lake and have a boat and SeaDoo

• Great for entertaining ..boating..fishingrelax
  ing...

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I have two Newfoundlands

• ..and they are great with children

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Due renovation team turn-over

• I ASSuMEd and my new team members ASSuMEd

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SIMmare 2

• The control room

CONNECTIVITY
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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

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My SIMteam
RU SON
CSC Director (MSN)
RHEC Site
RU West Site
2 MSNs, 1 IT Specialist 1 Admin Specialist II
2 MSNs, 1 IT Specialist 1 Admin Specialist II
VWCC
PHCC
JCHS
RU
WCC
NRCC
RU
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SIMmare 4

• Receiving and Installing 1.9 Million Dollars of
  Equipment

Of course spending was not the nightmare. Receivi
ng, installing and tagging all items gt 5000 and
all IT equipment was!
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Receiving Equipment - Laerdal
This doesn't look good
Humm

• Include on-site delivery installation
• in purchasing agreement

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Laerdal representative after receiving equipment
Sturgis DREAMS Russell returns to Virginia
Purchasing Agreement

• manikins, room furnishings, task trainers,
  virtual IV

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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 Annes
• 2 MegaCode 2 Nursing Kellys
• 2 Nursing 2 MegaCode Kids
• 2 Nursing Baby
• 2 Noelle
• 4 Adult 2 Peds Virtual IV,
• .

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Installing Equipment - Laerdal
Ouch! SimMan kicked me!
SimMan, try to behave yourself
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Laerdal representative after installation of
equipment
Sturgis DREAMING My new territory TEXAS!
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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 DVRs
• 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

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Installing A/V IT equipment
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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 students served (450
  students/semester)
• Increased volume of scenarios produced
• Back-up for staffing due to illness/surgery, time
  off.

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SIMmare 5

• Manikin responses are not in sync with monitor
  readings or scenario program

Another CONNECTIVITY Problem
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Nine Pin Problem

• SOLUTION
• Pull nine-pin cable through wall/ceiling and
  directly connect to laptop, i.e., by passing the
  rose boxes.

• 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)

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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

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CONTROL ROOM
Imagine No Monitors
Imagine No plan to connect manikin to the Laptop
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MED/SURG ROOM
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OB ROOM
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PEDIATRIC ROOM
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INTENSIVE CARE ROOM
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DEBRIEFING ROOM
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Lessons Learned Over TIME

• Scenario Development

• Revenue Planning

• Student driven
• Organization
• Admission ticket
• Incorporate pre/post encounter evaluation and add
  NCLEX ? to pre
• Reinforce concepts/nursing process included in
  admission ticket, pre-encounter, and scenario
• Incorporate NCLEX ?s

• Start early
• Partner and/or barter with as many organizations
  as possible
• Charge fee for unused time
• Block scheduling

Student Preparation Evaluation
Partnering/Bartering
Organized Debriefing
Scheduling
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Curriculum Integration

• Orientation
• Boot-camps
• Fundamental
• Front-loading
• Standardized patient encounters
• Mental health
• Assessment, HP
• Follow course syllabus when choosing scenario

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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..

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Student Driven NOT Operator Driven

• 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)

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Lessons Learned
Scenario Development 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

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Lessons Learned
Scenario Storage

• SCENARIO DEVELOPMENT REVIEW STORAGE

• Shared scenario storage system
• FinalSim houses all up-dated scenarios - batch
  file runs every night to load to Laerdal
  computers

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Lessons Learned
Preparation-Evaluation-Debriefing Putting it all
Together

• Assessing Preparedness

• Solutions to Assessing Preparedness

• Need better criteria to assess preparedness.
• Too much information in post encounter evaluation
  
• 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 post-encounter
  student questionnaires
• Incorporate nursing process in pre/post encounter
  evaluation
• Incorporate NCLEX question in pre-encounter and
  into debriefing

Data Collection
Solutions to Data Collection
The bigger picture
Solution to making a bigger impact
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Lessons Learned
Debriefing

• Student driven
• Incorporate admission ticket questions,
  pre-encounter into discussion
• Video review
• NCLEX question review

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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. Observe the client for a possibility of an
   embolic event.
2. Have a partial prothrombin time (PTT) drawn to
   completely evaluate the level of anticoagulation.
3. Prepare to administer protamine sulfate.
4. Monitor the client for signs of bleeding.

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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?

• Incorrect. If the client were at risk for an
  embolism, the INR would be very low, reflecting
  inadequate anticoagulation.
• Incorrect. PTT evaluates anticoagulation levels
  as a result of heparin, not warfarin.
• Incorrect. Protamine sulfate is the antidote for
  heparin, not warfarin.
• 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.

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Lessons Learned
Evaluation

• RAGE

• Nursing Process Driven
• Medication error reporting
• Curriculum integration questions

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Any questions?