Decompensating Pediatric Inpatient Scenarios
Case #4 – Septic Shock
FACILITATOR GUIDE
CONTENTS:
1. Facilitator guide
2. Session schedule (timeline)
3. Patient information sheet
4. Facilitator summary
5. Technician summary
6. Event progression for technician
7. Scenario progression
8. Debriefing guide
9. Evaluation form
BACKGROUND AND PURPOSE:
In July of 2009, Children’s National Medical Center (CNMC) Hospitalist and Emergency Department (ED) educators collaborated to create and implement unique simulation scenarios for trainees rotating on the Pediatric Hospitalist teams. The goal of this educational intervention is to teach and allow rehearsal of an approach to the unstable patient.
Monthly, a team of pediatric and family practice residents and medical students on each team are presented with the scenario of a decompensating inpatient. Trainees use this high-fidelity, low-risk, confidential environment to apply targeted clinical reasoning and their initial assessment and management strategies to core clinical problems.
Guided debriefing questions were created for the Hospitalist attending and fellow facilitators. These questions lead the trainees through exploration of the appropriate components of initial assessment and management, differential diagnosis of easily reversible and more complex etiologies, team leadership and collaboration, provider hand-offs and nurse-provider communication, and utilization of hospital resources.
IMPACT:
Since implementation, learners have uniformly given positive evaluations indicating that they subjectively feel that their competence in the assessment and management of unstable inpatients is improving. As trainees become even more proficient at timely recognition of sick patients and appropriate initial management, education, patient care, and safety outcomes are expected to benefit. In addition, the simulation environment provides the opportunity to assess learners’ competency with specific skills if rubrics for evaluation are created and applied to similar scenarios.
FACILITATOR INSTRUCTIONS:
No specific facilitator training is required. This guide may be helpful for the novice facilitator. This simulation resource may be used with or without the SimMan programsprovided.
- Briefly orient participants:
•Establish safe learning environment. This is the place to test your management style and potentially make mistakes in a safe environment.
•Ensure confidentiality.
•Clarify roles: Interns run scenario with senior as support. Facilitator not generally involved in scenario but can provide additional information/play the role of parent.
•Ask to suspend reality. These are situations which could really occur during this rotation. Although this is a plastic mannequin, treat it as you would a real patient to get the most out of the experience.
•Set expectations for involvement in debriefing.
•Introduce to code cart, and other available resources.
•Review capabilities of simulation center or equipment used.
- Provide the Patient Informationsheet to the participants.
- During the simulation the facilitator’s role can range from frequent guiding questions to support novice participants to silent observer for experts.
•If participants are stalled, consider redirecting through a guiding question regarding re-assessment or pausing the simulation to direct participants towards differential diagnosis or needed history. Consider whether being stalled without redirection could be itself be instructive.
•Remind of the capabilities of equipment.
•Provide additional information if asked.
•Document observations for later discussion.
•Stop simulation if not complete prior to end of allotted time in order to ensure adequate time for debriefing.
- You may utilize multiple methods to guide the debriefing/ reflection.
•Goals of debriefing:
-To encourage reflection on actions
-To focus on learning objectives
-To address skills, clinical reasoning, and emotions
•Methods:
-Open ended questions may be general or aimed at specific learning objectives.
-Present observations and inquire about rationale
-Plus/ Delta: The facilitator presents the patient’s changes and participants’
actions or a video of the simulation. Participants thenchoose positive actions
for plus column and actions they would change in delta column. The facilitator
then chooses where to focus. This method works better when more time is
allotted.
- Distribute and collect evaluations to help guide changes for futuresessions.
SESSION SCHEDULE
7:30Team arrives
Simulation center technician orients the team
Attending/ fellow divides learners into 2 groups
7:40Group 1 participates
Group 2 observes from control room
7:55Group 2 participates
Group 1 observes from control room
8:05 Debriefing begins
8:25Distribute & collect evaluations
Dividing the Group
Consider assigning the senior and intern/s to different groups to facilitate intern decision-making.
Observation Group Tasks
Ask each observation group to watch for aspects of patient care and communication so they can contribute to the debriefing.
Calling for help
Each group is expected to call for help. However in order to conform with reality and aid decision-making, the Code Blue or Rapid Response team should not arrive during the scenario. The code cart should be available, but only if a Code Blue was called.
PATIENT INFORMATION SHEET
Your Sign-Out
Patient: Herbie Walker
Weight: 60 kg
15 year old boy hospital day 2 with left tibial osteomyelitis and cellulitis, POD# 1 s/p PICC placement.
Osteomyelitis: Day 2 of Clindamycin with continued fever.
FEN: Regular diet. No IV fluids.
Disposition: Consider discharge after 5 days of IV antibiotics if afebrile.
Nurse Call
Patient is febrile to 40, heart rate 155, and he is vomiting. Please assess him.
FACILITATOR SUMMARY
Learning Objectives
After this simulation, the participants will be able to:
- Complete an initial assessment of a deterioratingpatient
- Recognize compensated and uncompensated shock
- Develop an initial plan for management of septic shock
- Determine when to escalate care to a rapid response team.
Scenario Summary(do not provide to participants)
15 year old boy admitted being treated for osteomyelitis and cellulitis via PICC who develops septic shock requiring rapid fluid administration and antibiotics.
Initial Patient Information(provide to participants)
Patient: Herbie WalkerWeight: 60 kg
15 year old boy hospital day 2 with left tibial osteomyelitis and cellulitis. POD# 1 s/p PICC placement.
Osteomyelitis: Day 2 of Clindamycin with continued fever.
FEN: Regular diet. No IV fluids.
Disposition: Consider discharge after 5 days of IV antibiotics if afebrile.
Nurse Call
Patient is febrile to 40, heart rate 155, and he is vomiting. Please assess him.
Significant Lab Values (provide only when asked):
On admission:
CBC: WBC 20, Hgb 8, PLT 500
CRP: 4 (normal < 0.5)
ESR: 40 (normal < 20)
BMP: normal
If repeated during scenario
CBC: pending
BMP: pending
Glucose: 150
CXR: normal
EKG: sinus tachycardia
TECHNICIAN SUMMARY
SCENARIO SUMMARY
Expected Simulation Run Time: 10-15 min x 2Debriefing Time: 20 min
Age: 15 yoWeight: 60 kg
15 year old boy being treated for osteomyelitis and cellulitis with antibiotics via PICC now with septic shock requiring rapid fluid resuscitation via large bore IV, antibiotics, and transfer to higher level of care for vasopressors.
EQUIPMENT
Setting/EnvironmentED
Inpatient floor
PICU
NICU
OR/ PACU
Outpatient clinic
Atrium/ lobby
Other:
Simulator Manikin/s Needed:
Sim Baby
Sim Man
Tracheostomy
Other:
Props:
Equipment attached to manikin:
IV fluids
IV medication
Oxygen. Route:
Monitor
ID band
Tube feeding
Central line PICC, no peripheral IV
Other:
Equipment available in room
FluidsIV start kit
IV tubing / Monitor available
Large syringes
Oxygen delivery device (nasal cannula, face mask)
ambu bag
suction (yankauer available but tubing not connected)
bulb suction
other:
Medications and Fluids
IV fluids @
Oral meds:
IV meds:
IM/ SC meds:
Diagnostics Available
Labs
x-rays (images)
12 lead EKG (sinus tachycardia)
Other:
Documentation
Sign OutH&P
Orders
VS flow sheet
I/O flow sheet
Other:
Recommended Mode for Simulation (i.e. manual, programmed, etc.)
EVENT PROGRESSION FOR TECHNICIAN
SCENARIO PROGRESSION
(includes additional information underlined)
Segment/ timing / Mannequin / Participant ActionsInitial assessment
2-3 minutes / VS:
T 39.4
HR 155
RR 22
BP 100/44
O2 Sat 95%, RA
mPEWS 3
PE:
Patient states “I don’t feel well”
Cap refill 2-3 sec / Assessment
□Check consciousness/ breathing/ color (PALS) or pediatric assessment triangle
□Primary assessment (ABCDE). See PE
□Obtain further hx: PMH – none, Home meds – none, Allergies – NKDA, FMH – non-contributory.
□Apply monitor
□Check BP
□Secondary assessment/ head-to-toe exam
□Re-assess BP after each intervention
□Order blood culture
Interventions
□Optimize access to patient
□Assemble and test emergency equipment (oxygen, bag-valve mask, suction)
□Open airway (sniffing position, jaw thrust or head tilt/ chin lift)
□100% FiO2 via non-rebreather
□Place large bore IV x 2 or place IO
□20 ml/kg normal saline bolus with rapid technique up to 60 mL/kg or until normotensive.
□Order broad spectrum antibiotics
□Call Code Blue, not CAT when bradypneic
Clinical Reasoning
□Recognize shock
□Ddx of shock
□Recognize that PICC is not adequate for fluid resuscitation
□Consider transfer to higher level of care
Becomes hypotensive
2-3 minutes / VS:
T 39.5
HR 175
RR 35
BP 85/40 70/33
O2 Sat 90%
PE:
Minimally responsive
Thready peripheral pulses
1+ central pulses
Mottled skin
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Decompensating Pediatric Inpatient Scenarios
Case #4 – Septic Shock
Case resolution
The patient was given 3 normal saline boluses prior to arrival of the Rapid Response Team with some initial improvement in his blood pressure. But he became hypotensive shortly after requiring transfer to ICU for vasoactive therapy. His blood culture grew MRSA resistant to Clindamycin. He improved with Vancomycin while awaiting the culture results.
FACILITATOR DEBRIEFING GUIDE
Briefly orient participants to debriefing
1. Remind of safe learning environment and confidentiality.
2. Communicate expectations to be active and vocal in evaluation of their own performance and that of the team.
3. Remind that your role is of facilitator/ guidance, not lecturer.
Targeted debriefing questions
1. Summarize the concerns about the patient and the events that occurred during the scenario.
2. What was your initial impression of the patient?
Airway: Maintainable
Breathing: Hypoxemia, tachypneic, adequate ventilation
Circulation: Tachycardia for age, normotensive, widened pulse pressure
Disability: Normal mental status, normal dextrose
Exposure: Febrile
3. Based on your initial evaluation, what was your impression of this patient?
Compensated shock
What is shock? A clinical state in which blood flow and delivery of tissue nutrients do not meet metabolic demand
What is compensated shock? HR increases to maintain cardiac output in an effort to meet increased demand or to compensate for inadequate volume, anemia or vasodilatation. Resources shunted to vital organs. BP remains normal
What is hypotensive shock? Inadequate tissue oxygenation due to inadequate perfusion and/ or oxygenation. Organ and cellular function deteriorate. BP falls.
4. What are the clinical signs/symptoms of shock?
Signs of inadequate perfusion or tissue hypoxia
Peripheral vasoconstriction
Delayed capillary refill
Diminished pulses
Cool extremities
Peripheral vasodilation
Brisk capillary refill
Bounding peripheral pulses
Widened pulse pressure
Signs of inadequate end organ perfusion/oxygenation
Decreased urine output
Altered mental status
Mottled skin
5. Based on this patient’s history and clinical findings, what is the likely etiology of his condition?
Septic Shock
6. What was you management strategy for this patient’s septic shock?
IVF to restore effective circulating volume, oxygen administration, broad spectrum antibiotics
7. How did you assess whether your initial treatment was effective?
Repeat initial assessment periodically and after each intervention (ABCDE)
8. What constitutes adequate fluid resuscitation?
•20ml/kg at a time – rapid MANUAL push with goal of within 5 minutes
•60ml/kg given rapidly within 60 minutes (3 - 20ml/kg boluses)
•Most children require 40-60 ml/kg in the first hour, some may require up to 200ml/kg in the first few hours
•For fluid sensitive pediatric patients (cardiac or renal patients), give 10ml/kg boluses
•Watch for complication of excess fluid resuscitation is pulmonary and systemic edema (increased WOB, rales, gallop rhythm, or hepatomegaly)
9. This patient had a PICC line. Why were you satisfied/ dissatisfied with this form of vascular access?
•Long line difficult to push fluids/meds as quickly as a short line. Increased risk of rupture with rapid push.
•Need 2 large bore short lines or intraosseous cannulation in patients with shock
10. Did you feel comfortable managing this patient on the acute care floor? What additional resources did you feel the patient needed?
•Hospital Specific
Take home points
- Patients with normal blood pressures can be in shock.
- Patients in shock may require more than 60 mL/kg of isotonic fluids.
- When giving more than 60 mL/kg strongly consider vasoactive drugs.
- PICC lines will not infuse rapidly enough to provide fluid resuscitation.
- When concerned, call for help.
References
1. American Heart Association. Pediatric Advanced Life Support Provider Manual. 2006. AHA.
2. Roback, Mark; Teach, Stephen. Pediatric Resuscitation: A Practical Approach. 2005, American College of Emergency Physicians.
3. American Heart Association. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. 2006. AHA.
4. Marino, Paul L. The ICU Book. Second Edition. Williams & Wilkins 1998.
5. American Heart Association. 2010 American Heart Association Guidelines for CPR and ECC. 2010.
6. Brierley et al. Clinical practice parameters for hemodynamic support of pediatric
and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009 Vol. 37, No. 2.
EVALUATION FORM
- Simulation Date: ______
- Simulation Instructor: ______
- Scenario: Septic Shock
Simulation Evaluation:
- My orientation to the simulation center was adequate.
Strongly disagree / Disagree / Neutral / Agree / Strongly Agree
- The information and concepts addressed will change the way I practice.
Strongly disagree / Disagree / Neutral / Agree / Strongly Agree
- The debriefing facilitator was effective at conveying concepts and provoking thought.
Strongly disagree / Disagree / Neutral / Agree / Strongly Agree
Clinical Confidence:
I feel comfortable with my ability to:
Prior to session / After session1-strongly disagree 2-disagree 3-neutral 4- agree 5-strongly agree
4. perform initial assessment of decompensating patient / 1 2 3 4 5 / 1 2 3 4 5
5. recognize shock / 1 2 3 4 5 / 1 2 3 4 5
6. manage shock / 1 2 3 4 5 / 1 2 3 4 5
7. call for help in an emergency / 1 2 3 4 5 / 1 2 3 4 5
Comments:
- What did you learn?
- What remains unclear?
- Other comments: