| 1 - Instructions for the participant/student/candidate |
| 1.1 Orientation for the team - Pre briefing
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| In the pre-briefing, the facilitator should explain the need for "suspension of disbelief" in order for them to engage in the realism of the clinical case of in situ simulation. They will also check the assembly of the patient and the simulated scenario, so that they are in accordance with what they are used to working on a daily basis. It is also a moment to remove doubts about the behavior during the development of the simulated scenario. |
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With the entire team properly positioned, the facilitator should distribute Form 1 (Professional identification of each team member) and provide the guidelines as follows:
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1) An in situ simulation will be carried out to evaluate the multidisciplinary team in the workplace itself, instead of taking everyone to the simulation laboratory.
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2) The behavior of the team members should be routine for the clinical situation that will be simulated, and the greater the suspension of disbelief regarding the realism of the scenario was planned, the easier and more natural everyone's performance will be.
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3) The simulation will have 5 stages: 1) pre-briefing (which is this current phase), 2) briefing, 3) scenario development, 4) scenario closure and 5) immediate feedback (right after closing) by the local team and, late feedback.
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After the above explanations, it should be informed that the pre-briefing is the period in which the facilitator identifies the expectations of the participants, explains how the simulated scenario is set up and what are the roles to be played by the multidisciplinary team during its development, as well as guidance to the participants about the physical space, equipment, consumables and simulator/mannequin.
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The facilitator should deliver the material for the assembly of the scenario and the simulated patient, describing it:
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The simulated scenario will be set up in a bed in the emergency room with a patient on a stretcher, with a cardiac monitor and pulse oximetry installed, in spontaneous ventilation with a nasal catheter or O2 mask without a reservoir coupled to the flowum, and venous access by peripheral puncture in the left forearm.
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The professionals of the team who will provide the care, whose final assembly of the scenario will be at the discretion of the service (nursing, doctors, nursing technician and physiotherapist) will start the scenario to the right of the patient, identified with badges that show the professional function of each
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The necessary material should be provided and checked by those involved soon after the start of the simulation scenario. The choice of materials and equipment with their packaging is at the discretion of the team.
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For the start of the simulated scenario, the facilitator will be positioned at the lower end of the stretcher. Towards the patient's left foot, the filming assistant will be able to have a full view of the monitor, patient, staff, and devices.
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| 1.2 - Staff Orientation - Briefing |
| Case report |
| The facilitator should explain that the briefing is the moment when the specific clinical case will be presented and the tasks to be performed by the multidisciplinary team will be defined. |
| In the briefing, the facilitator should provide information about the clinical case and the task to be performed. Pay special attention to the end goal of the mock case. It is also a time to remove doubts about the clinical case and the execution of tasks. |
| It should explain that after the start of the simulated scenario, the performance of the team members should be the same as on a day-to-day basis for the tasks that will be performed. |
| At any time, if they have questions about the patient's clinical parameters and/or physical examination data, they should be asked of the facilitator. |
| Communication between team members needs to be clear and actions taken aloud so that the facilitator and evaluators can hear. |
| If you have any questions, please ask the facilitator. |
| The facilitator should inform the closing time of the simulated scenario. |
| After the end of the simulated scenario, the facilitator should distribute the updated protocol on sedation/analgesia of children for emergency procedures, providing immediate feedback on the performance of the teams during the execution of the simulated scenario |
| If the application of the simulated scenario is recorded, it will be possible to review the video with a new application of the technical and non-technical checklists, comparing the result with the result of the immediate application. Subsequently, it will be possible to provide late feedback, discussing the execution of the tasks by the multidisciplinary team. |
| After these explanations, the facilitator should tell the case below: |
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Child, male, 05 years old, 20kg, admitted to the emergency room of a hospital, fasting for 6 hours, requiring chest drainage. It presents with inhalational support of O2, 2L/min, maintaining pulse oximetry around 99%. Minimal respiratory effort, febrile and tachycardic. On physical examination, the patient presented diffuse and bilateral rales and decreased breath sounds at the base of the right hemithorax. Supportive care was performed, the SEPSIS protocol was initiated, and then a simple chest X-ray was performed (attached) showing a 2⁄3 veiling of the right hemithorax (see Imprint 2), compatible with voluminous pleural effusion, with indication of puncture and thoracic drainage. An evaluation of the surgical team was requested to perform the procedure. The care team should provide the necessary preparation and materials for its realization. The surgeon has the function of performing the puncture and thoracic drainage procedure. The sedation/analgesia of the patient will be the responsibility of the pediatrician.
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| Tasks |
| In the next 15 to 20 minutes, the multidisciplinary team should perform the following tasks: |
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• Identify and prepare the necessary equipment for the medical procedure.
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• Perform patient sedation for the procedure in the emergency room.
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• In case of complications, identify and carry out the necessary immediate conducts, including emergency procedures, according to the standard technique.
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• Follow the facilitator's instructions.
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| 2) Instructions on the simulated scenario |
| Description of the scenario |
| The simulated scenario will be set up in a bed in the emergency room with a patient on a stretcher, monitored with a cardiac monitor at the head of the bed with pulse oximetry, in spontaneous ventilation with a nasal catheter or O2 mask without reservoir, coupled to a flowmeter and peripheral venipuncture. |
| The professionals of the team who will provide care, whose final assembly of the scenario will be at the discretion of the service (nursing, doctors, nursing technician and physiotherapist) will start the scenario to the right of the patient, identified with badges of different colors that show the professional function of each one. After the start of the simulated scenario, the movement of professionals is free. |
| The facilitator will be positioned at the lower end of the stretcher, further to the right. Towards the patient's left foot, the filming aid should be positioned, as this will have a complete view of the monitor, patient, team and devices used. |
| During sedation for the procedure: |
| The crisis situation (distractor) will be initiated by the facilitator and will occur when the stretcher is in an equidistant location between the starting point and the arrival point (radiology sector). |
| Final: |
| The facilitator will define the closing time of the simulated scenario. |
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3) Station Assembly Checklist
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| Position of the participants and arrangement of the furniture. |
| Initially, the members of the multidisciplinary team should position themselves to the right of the patient (Figure 3). The facilitator will be positioned at the bottom of the stretcher on the right side and the filming assistant will also be at the bottom of the stretcher, but more on the left side so that he can have a privileged view to film all the individuals and processes that will occur. |
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| 4) Human resources to conduct the scenario: |
| Available Resources |
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Participants
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• Lab coats or private hospital
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• Identification of professional function (as per model attached)
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• Materials pertinent to the function (stethoscope, goggles, gloves, etc.)
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Simulated Patient:
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• Children’s shirt
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• Children's Bermuda shorts
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• Par de chinelo infantil
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| 5) Material resources |
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• Fio Mononylon 3-0 and Polypropylene 3-0
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• 1 Thorax drain 20, 22 and 24
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• 1 Water seal collector
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• 1 Suction probe no 06
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• 1 O2 nasal catheter
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• 3 Scalps of various sizes
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• 3 Jelcos nos 20, 22 and 24
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• 3 Packets of Gauze
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• 1 Pack of Compress
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• 4 Tracheal tubes with cuff no. 4.0; 4; 5; 5,0; and 5.5
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• 1 Saline solution 500ml
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• 1 Medium Micropore Roll
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• 1 Roll of Medium Adhesive
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• 2 x 5ml syringes
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• 2 x 10 ml syringes
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• 1 Box of M procedure gloves
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• 1 Box of G-procedure gloves
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• 1 Patient - low-cost manikin.
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• 1 patient bed
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• 1 Ambu and mask with reservoir
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• 6 vials each identified with the following drugs: Propofol, Fentanyl, Midazolam, Ketamine, Adrenaline and Dobutamine.
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• 1 Laryngoscope blade 2
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• 1 Laryngoscope slide 3
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• 1 Bed Sheet
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• 1 Children's shirt
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• 1 Children's Bermuda shorts
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• 1 Children's Sadalia
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• 2 Cell phones or camcorder
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• 1 Box of Minor Surgery Supplies
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| Printed |
| The following forms are available, as described in the previous items: |
| 1. Identification of team members |
| 2. Initial Parameters of Vital Signs Monitor |
| 3. Simulated patient X-ray |
| 4. Vital signs monitor parameters during the first complication |
| 5. Vital signs monitor parameters during the second complication |
| 6. Vital signs monitor parameters after resolution of the second complication |
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| 6) Guidelines for the simulated participant (patient, family member, team member, etc.) |
| 6.1) Simulated Patient Information: |
| Dummy/Simulator: |
| Shop mannequin, already prepared, according to the instructions of the making off. |
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6.1.1 Suit:
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• Shirt, shorts and flip-flops.
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6.1.2 Devices:
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• Nasal catheter or non-rebreathing O2 mask attached to the patient
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• Monitor and oximeter attached to the patient
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| 6.2) Information about the simulated family member and standardized script |
| It could be the father or the mother. You should be extremely concerned about your child's condition, all the time asking for information and what will happen. |
| If the team members ask any questions, you should say that you don't know anything because you are separated and the child was with the other spouse. |
| You should be instructed by the team members to leave the room during the preparation and procedure, and that you will be informed after the end of the procedure. |
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During the first event:
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The simulated family member was close to the door when the first incident began and should try to re-enter the room, in a very nervous way, carrying his cell phone on and talking loudly:
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- Why are they taking so long?
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- Why doesn't anyone tell me what's going on?
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"I need to talk to the staff now, otherwise I'm going to raid the place." I'm filming everything!
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Clarifications should be provided to the family member and asked to stop filming and say that there is no authorization for filming in this location. After proper guidance, the simulated family member collects the footage, thanks it and leaves the scene.
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| During the second intercurrence: |
| The simulated family member will not interfere, as they will not be present. |
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| 7) Guidance and information for the facilitator/examiner/evaluator: |
| Case and Scenario Information |
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- Case Category:
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| Pasive medical procedure in the pediatric emergency room requiring on-site sedation, with complications due to malfunction of venous access, and incomplete infusion of medication with lack of effectiveness in sedation to perform the procedure, presenting agitation. Secondly, with a new venous access, the new infusion of sedative drug will lead to a decrease in the level of consciousness and the need for ventilatory support. |
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- Fulfillment Scenario:
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| Paediatric emergency |
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- Fulfillment Scenario:
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| • Identification of professionals working in the target sector of the simulation. |
| • Materials for filming. |
| • Simulated family member wanting attention and talking to professionals during the intercurrence. |
| • Continuous patient monitoring. The data from the monitor will be narrated and presented by the facilitator. |
| • Supplies for peripheral venous access, invasive and non-invasive ventilation, and drugs for sedation. |
| • Materials for emergency surgical procedure. |
| Purpose of the case and brief description |
| Perform a multiprofessional in situ simulation in a daily scenario of performing an invasive procedure in the emergency room, aiming to identify opportunities for improvement and evaluation of the effectiveness of this method for training and feedback of professionals involved in the care of pediatric patients accompanied by family members, specifically in a crisis situation. |
| This 5-year-old pediatric patient will undergo an invasive procedure in the pediatric emergency room. |
| The initial sedation of the patient will not be effective, there will be psychomotor agitation and impossibility of performing the procedure. |
| The simulated family member will enter the scene at this time with cell phone in hand, as he heard the child's complaint. The team should take appropriate action if the family member has not been previously informed. |
| In the investigation of the ineffectiveness of sedation, the extravasation of the infused contents in the peripheral venous access should be evidenced, verifying its malfunction. |
| After a new venipuncture, the new infusion of sedative drugs will cause a decrease in the level of consciousness and the need for ventilatory support (manual ventilation with AMBU, followed by maintenance with an O2 mask with a reservoir). |
| Throughout the service, a family member will show anxiety and request contact with the team. |
| Team members should identify what happened and act together to find the most appropriate solutions to the incidents and distractors created at this time. |
| All the material necessary for the conduct of the case must have been provided after the start of the simulated scenario. |
| Instructions to the facilitator |
| 1) In the pre-briefing - Guide the team to assemble the simulated patient (low-cost manikin) in an appropriate manner, identifying the role of each team member (Imprint 1). |
| 2) No briefing - Explicar o caso clínico mostrando o Impresso 2 (Radiografia de tórax) e a tarefa aos membros da equipe multiprofissional. Dar ênfase que o objetivo final é a realização do procedimento de drenagem de tórax, mas que a técnica do procedimento não será motivo de avaliação. |
| 3) Após o início do cenário simulado: |
| a) When professionals ask about the patient's clinical parameters and/or physical examination, Form 3 should be shown with the vital signs - Sat.O2 90%, HR 100 bpm, RR 22 irpm, T 37ºC, BP 110 x 70 mmHg - The facilitator should narrate the parameters. |
| b) When those involved in the care are going to administer any medication, they should say out loud the medication and the dose, then the facilitator will answer: "Medication performed". |
| 4) Define the time to report the two complications: |
| a) The facilitator should trigger the crisis situation when the nursing team says that the sedative drug was administered at the request of the pediatrician. The surgeon will be on hand and will arrive as soon as the simulated patient is ready for the procedure. |
| b) Verbally explain the first complication, with the clinical picture of psychomotor agitation of the patient and the physical examination of the patient, when requested, and show Form 4 with the vital signs - Sat.O2 90%, HR 120 bpm, RR 28 irpm, T 37ºC, BP 110 x 70 mmHg. To determine the surgeon's inability to proceed with the procedure (Motor agitation, tachycardia (HR of 100 rose to 120 bpm, RR of 22 to 28 ipm), maintaining saturation of 90%) and complaint of pain at the access site. |
| c) Talk about extravasation in peripheral access, if asked about it. |
| d) Verbally request the dose of medications administered during the procedure. |
| e) To state the effectiveness of the procedures performed (new access established and new effective administration of drugs). |
| f) Announce the 2nd intercurrence (Imprint 5 - The facilitator narrates and shows the parameters - HR = 120 bpm, RR = 12 irpm and Sat.O2 = 85%, with lowering of the level of consciousness) |
| g) After brief ventilation with a mask and AMBU, the facilitator will confirm the effectiveness of ventilation after its establishment (invasive or not) and should choose to remove the catheter and place a mask with an oxygen reservoir, allowing the procedure to be performed. At this point, you must submit Form 6.
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| h) The facilitator should authorize the sequence of the procedure when the crisis is resolved (patient sedated and with effective ventilation). |
| 5) Define the closing time of the scenario: |
| a) Close the case as soon as the patient is at a good level of sedation, after resolution to the satisfaction of the two distractors, the surgeon will inform the beginning of the procedure. |
| b) Close the case, if there is no identification or if there is no solution to the complication after 5 minutes. |
| Instructions to evaluators: |
| There will be two evaluators per scenario, one responsible for filling out the technical checklist and the other for the non-technical checklist (evaluation of the multiprofessional team). |
| The evaluators should be previously trained and should check all the topics and items of each checklist to remove doubts and be familiar with the sequence. These doubts will be cleared up with the facilitator before the start of the simulated scenarios. |
| If, during the development of the scenario, there is any doubt about any marking that should be made, a description of the situation encountered and any doubts should be made, and then ask the facilitator at the end of the simulated scenario. |
| The initial completion of the checklist can be on paper, precisely so that all doubts are resolved, before entering the data in the computerized form of the checklist or starting with the computerized checklist. |
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| 8) Information about the case and actions to be taken: |
| The fundamental items for the procedure should be checked, according to the attached checklist. |
| The procedure should be explained to the simulated family member at the beginning of the scenario, and asked to leave the room momentarily. |
| Let the team make your identification (Printout 1), organize themselves as usual and make the initial infusion of the drugs used and prepare for the surgeon to perform the procedure. They should be familiar with the clinical case and the chest X-ray (Printout 2) that shows the need for pleural drainage. |
| When the professionals ask about the clinical parameters and/or physical examination of the patient, Form 4 - Sat.O2 90%, HR 120 bpm, RR 28 irpm, T 37ºC, BP 110 x 70 mmHg should be delivered. Thus, the presence of psychomotor agitation, tachycardia (HR of 100 rose to 120 bpm, RR of 22 to 28 bpm), maintaining saturation of 99%) and complaint of pain at the access site should be noted. |
| - When those involved in the care are going to administer any medication, they should say out loud the medication and the dose, then the facilitator will answer: |
| - Medication performed. |
| - The possibilities for ineffective sedation, including venous device dysfunction, should be checked. |
| - The simulated family member who will act as another distractor of the communication of accomplishment entering the scenario with the cell phone on, must instigate the following aspects. |
| - Why are they taking so long? |
| - Why doesn't anyone tell me what's going on? |
| "I need to talk to the staff now, otherwise I'm going to raid the place." Look, I'm filming everything. |
| Clarifications should be provided to the family member and asked to stop filming and say that there is no authorization for filming in this location. |
| - After proper guidance, the simulated family member collects the footage, thanks it and leaves the scene. |
| - Another access should be arranged and the medication should be taken again. |
| The Facilitator should confirm aloud the drug infusion and expose the new clinical picture and show the vital signs (Imprint 5 - The facilitator shows and narrates the parameters - HR = 120 bpm, RR = 12 ipm and Sat.O2 = 85%, with lowering of the level of consciousness) |
| - After brief ventilation with a mask and AMBU, the facilitator will confirm the effectiveness of ventilation after its establishment (invasive or not) and should choose to remove the catheter and place a mask with an oxygen reservoir, allowing the procedure to be performed (Imprint 6). |
| The facilitator should inform that the case is closed after the surgeon indicates the start of the procedure. |
| The facilitator must inform that the case is closed if it is not resolved within 05 minutes after the second intercurrence. |
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| 9) Flowchart of possible decisions of the stations It is a graphic representation of the scenario, containing the possible decisions of the participants, and guiding the facilitator/evaluator, in the sequence of conducting the case, based on these decisions |
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| 10) Technical & Non-Technical Checklist (Topics & Items) |
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10.1) Technical Checklist
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| The Evaluators should be selected together with the facilitator and will be present from the beginning of the instructions to the multidisciplinary team. It is important to instruct the evaluators about the need to note the start times of each topic and item marked in the right side column of the checklist, with time zero (T0) being the moment when the facilitator announces the beginning of the simulated scenario. The other times (T1 to T15) should be counted and noted from T0 onwards. |
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| Evaluation indicators |
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T0= |
| A |
Check Items for the Procedure |
Yes |
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No |
T1= |
| 1 |
Separation of the materials to be used to perform the invasive procedure. |
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| 2 |
Separation of materials to be used in complications involving sedation in pediatrics. |
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| 3 |
Adequate and private space was provided for the procedure. |
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| 4 |
The multidisciplinary team was available at the time of the procedure. |
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| B |
Orientations for family members |
Yes |
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No |
T2= |
| 1 |
He reassures family members about the procedure and asks them to wait outside the room until the end of the procedure. |
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| 2 |
Approach to the stressed family member when the 1st complication occurs. He provided an explanation of the situation and the need to wait outside the emergency room while the procedure is performed.
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| 3 |
It advises the family member that after the procedure they will talk about the procedure, prognosis and complications. |
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| C |
Use of sedation/analgesia scales |
Yes |
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No |
T3= |
| 1 |
Michigan |
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| 2 |
Ramsay |
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| 3 |
Ramsay modificada |
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| 4 |
Confort |
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| 5 |
Other: |
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| D |
Parameters for sedation * Inappropriate administration of the drug is outside the established dosages
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Did not |
Inadequate |
Adequate |
T4= |
| 1 |
Propofol (P) 1 a 3 mg/kg |
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| 2 |
Fentanil (F) 20 a 30 mcg (0,02 a 0,03mg ou 0,4 a 0,6mL), EV, a cada 10 a 12kg de peso corporal. |
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| 3 |
Midazolam(M) 0,1 a 0,4 mg/kg |
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| 4 |
Cetamina (C) 0,5 a 2mg (EV/IO) 2-4mg/kg (IM) |
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| 5 |
Etomidato (E) 0,2 a 0,4 mg/kg |
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| E |
Technical Skills |
Did not |
Inadequate |
Adequate |
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| 1 |
Infusion of medication into venous access |
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T5= |
| 2 |
Valuation of psychomotor agitation and alterations of vital parameters |
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T6= |
| 3 |
Identification of the first complication with the patient |
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| 4 |
Identification of venous access dysfunction |
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| 5 |
Obtaining new peripheral vascular access |
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T7= |
| 6 |
Obtenção de novo acesso vascular periférico |
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T8= |
| 7 |
Performed the infusion of new sedative/analgesic drugs Propofol (P) 1 a 3 mg/kg Fentanil (F) 20 a 30 mcg (0,02 a 0,03mg ou 0,4 a 0,6mL), EV, a cada 10 a 12kg de peso corporal. Midazolam(M) 0,1 a 0,4 mg/kg Cetamina (C) 0,5 a 2mg (EV/IO) 2-4mg/kg (IM) Etomidato (E) 0,2 a 0,4 mg/kg
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T9= |
| 8 |
Identification of the second complication with the patient (decreased consciousness, hypoxia and hypoventilation) |
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T10= |
| 9 |
Identification of the need for ventilation |
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T11= |
| 10 |
Momentary ventilation with AMBU and O2 mask with reservoir |
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T12= |
| 11 |
Replacement of the O2 catheter for a mask with a reservoir at 5 L/min |
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T13= |
| 12 |
Identification of normalization of vital signs |
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| 13 |
Identification of the appropriate level of sedation and analgesia |
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T14= |
| 14 |
Resumption of the possibility of performing the surgical procedure |
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T15= |
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10.2) Non-technical checklist
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| MHPTS Scale* Part I |
Evaluation of the team's performance in each item during the actions |
| Evaluation indicators |
0 Never or rarely |
1 Inconsistent |
2 Consistent |
| Consistently mark when the many qualities described in each item have been demonstrated in the actions |
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| 1 |
A leader is clearly recognized by all team members. |
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| 2 |
The team leader ensures that an appropriate balance is maintained between command authority and team member participation. |
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| 3 |
Each team member demonstrates a clear understanding of their assignments. |
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| 4 |
The team guides each one to meet all significant clinical indicators during procedures/interventions. |
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| 5 |
When team members are actively engaged with the patient, they verbalize their activities out loud. |
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| 6 |
Team members repeat or paraphrase instructions or clarifications to indicate that they heard correctly. |
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| 7 |
Team members indicate established protocols and checklists for the procedure/intervention. |
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| 8 |
All team members are properly involved and participate in the activity. |
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| Items 9-16 may be marked “NA (not applicable)” if there are no situations in which these types of responses are necessary. |
| MHPTS Scale* Part II |
Evaluation of the team's performance in each item during the actions |
| Evaluation indicators |
0 Never or rarely |
1 Inconsistent |
2 Consistent |
NA Not applicablel |
| The items below can be marked as “NA (not applicable)”, if necessary, according to the situations demonstrated or not by the teams |
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| 9 |
Disagreements or conflicts between team members are addressed without loss of control of the situation. |
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| 10 |
When appropriate, roles are swapped to address urgent issues or emerging events. |
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| 11 |
When instructions are unclear, team members acknowledge their lack of understanding and ask for repetition and clarification. |
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| 12 |
Team members acknowledge - in a positive way - guidance aimed at avoiding or containing errors, or seeking clarification. |
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| 13 |
Team members pay attention to actions that they feel could cause errors or complications. |
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| 14 |
Team members account for potential errors or complications with procedures by avoiding them. |
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| 15 |
When statements intended to prevent or contain errors or complications do not elicit a response to avoid or contain the error, team members persist in finding an answer. |
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| 16 |
Team members ask each other to help each other, before or during periods of task overload. |
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