Vol. 6 Issue 11
Prepping for Real Life
The Patient Safety Institute at North Shore-Long Island Jewish prepares nurses to handle whatever healthcare situations arise
Admitted to the CCU 2 days ago with severe chest pains and shortness of breath, Mr. Brennan seemed to be doing much better at change-of-shift report. There was even talk of transferring him to a step-down unit the next day.
But in the middle of the night, his blood pressure started to plummet and he became non-responsive. The novice critical care nurse assigned to Mr. Brennan took a deep breath, recalled what she had learned that week in her Critical Care Fellowship Program and began implementing a series of interventions to stabilize her patient. An hour later, he was again alert and clinically stable.
Afterward, the nurse sat down to view a videotape of the scenario and share in a critique of her performance.
At the newly inaugurated Patient Safety Institute of the North Shore-Long Island Jewish (LIJ) Health System in Hauppage, NY, lifesaving lessons such as this one are everyday occurrences.
Mr. Brennan is actually one of three life-like, computerized mannequins that allow novice nurses to practice critical care skills in realistic scenarios in a safe and nurturing environment.
The high-tech patient simulation lab is the crown jewel of the 5,000-square-foot Patient Safety Institute, the newest facility within North Shore-LIJ's Center for Learning and Innovation.
"I think this is going to be quite significant for us in terms of IHI (Institute for Healthcare Improvement) initiatives, CMS (Centers for Medicare & Medicaid Services) and JCAHO standards, and other patient safety measures," said Kathleen Gallo, PhD, RN, chief learning officer.
When the Institute of Medicine released its "To Err Is Human" report in 2000, estimating that up to 98,000 people die every year in U.S. hospitals from medical errors and hospital-acquired infections, North Shore-LIJ created a goal of zero tolerance for these problems within its 15-hospital network.
"My background is in ED and trauma services, and 5 years ago my CEO asked me if I'd create a corporate university, which is how the Center for Learning and Innovation came into being," Gallo explained. "We devoted the first 4 years to management development but, being a nurse, I always knew we had to tackle clinical problems as well."
At a conference of chief learning officers, Gallo met Mike Barger from Jet Blue, who had been a Top Gun pilot in the Navy and successfully trained hundreds of airline pilots.
"I went over to him and asked, 'Mike, tell me how you train fighter pilots,'" Gallo recalled. "We're both in very tough industries with small bottom lines, and hire people who are performing critical tasks with lives at stakes. We talked about flight simulators, and I walked away determined to research and obtain the best possible simulators for our clinicians."
At the patient simulator lab in the Patient Safety Institute, the clinical scenarios are very true to real life. Trained critical care instructors sit behind a one-way mirror and use a computer to create a virtually endless array of clinical situations, from stroke and heart attack to amputation or other trauma.
"We immerse the nurses in the moment, so they actually feel they're at work, complete with their usual working uniform," Gallo said. "In addition to the critical care patient simulation lab, we have ED bays and an OR room set up for simulation."
The patient care simulations are videotaped and reviewed during a debriefing that helps cement the learning experience.
"The nurses look at themselves not only clinically, but in how they treat one another in a crisis," Gallo said. "As they progress and gain competency, we dial up the intensity and complexity of the simulations.
"We train new grads or non-critical care nurses to function competently and confidently, so incumbent nurses don't see them as a burden when they come to the critical care areas."
Critical Care Fellowship
Lee Dairo, RN, is currently part of the Critical Care Fellowship Program at North Shore University Hospital in Manhasset. She spends 2 days a week in the computer lab, completing the American Association of Critical-Care Nurses' Essentials of Critical Care Orientation curriculum online. She's also scheduled for 2 days a week in the neuro ICU under the preceptorship of seasoned critical care nurses called associate and master fellows, spending the fifth day in the patient simulation lab.
"Everything we've learned during the week, we practice in the lab on the mannequins," Dairo noted. "The mannequin does everything a real patient does coughs, breathes, talks about pain and goes into arrest. We can draw blood, start IVs, take vital signs and everything else we would do in the ICU."
The simulation lab is very helpful in sorting out all the lines going into critically ill patients. "We learn about central venous pressure, arterial and Swan-Ganz lines, and what our responsibility is for each of them," Dairo continued. "We'll learn how to take wedge pressures, how to read wave forms on the monitors in the lab, when to notify the physician and what nursing interventions to implement in different situations."
Behind the Curtain
Barbara DeVoe, MSN, CFNP, director of clinical education programs, laughingly described herself as "the person behind the curtain," who along with Director of Academic Affairs Mary Mansfield, MSN, RN, runs the clinical scenarios in the simulation lab.
"We can tailor the clinical scenarios to reflect the curriculum that [the nurse fellows] are currently studying," she explained. "For example, I can create a cardiac event when they're dealing with the cardiac part of the program, making the mannequin bradycardic, having him go into ventricular tachycardia or putting him into an arrest situation."
By videotaping the scenario, the instructors create a perfect feedback mechanism for novice nurses.
"During the debriefing, the nurses can see when they hesitated during an emergency, or they can affirm, 'I did the right thing,' which is very enlightening," DeVoe said. "If it's not the right thing, we have a chance to make it right in the safe environment of the simulation lab.
"When the students do make an error, there's an 'ah-ha' moment that teaches them so very much."
In addition to the invaluable clinical skills the nurses learn in the simulation lab, they establish competency and confidence in nurse/patient interactions within the critical care setting.
"The master fellows who serve as preceptors in the critical care units have noted this particular class is not at all shy, that they project a confidence and competence because they've gained technical proficiency as well as critical-thinking skills in the laboratory setting," DeVoe said.
Dairo, who described herself as a hands-on learner, said she finds the simulation lab helps cement her learning.
"On the unit, all those IVs, lines, ventilators and other equipment can be overwhelming," she admitted. "Here in the lab, we can take it one step at a time and develop a comfort level. Sometimes, I go out of here after a day in the simulation lab and my head is spinning. But when I go onto the unit, I realize, 'OK, I can handle this situation because I've already experienced it in the lab."
Sharing With the Community
The Patient Safety Institute is open to other disciplines within the health system as well.
"We anticipate our own critical care nurses will be able to use the lab to demonstrate continued competencies, respiratory therapists and physicians will choose to do some of their learning here, and EMS personnel will find the institute invaluable," DeVoe said. "We're also in the process of setting up business meetings to offer area colleges, universities and other hospitals access to the Patient Safety Institute."
EMS personnel in particular will benefit from the Institute's disaster preparedness scenarios offered through its dedicated simulator. This is in connection with North Shore-LIJ Health System's designation by the state as a Regional Bioterrorism Resource Center.
"We're happy to partner with any of the nursing or medical schools in the area and, as time goes on, with other hospitals as well," Gallo said. "Part of being a healthcare leader is sharing with everyone else.
"There's no competition when it comes to patient safety!"
Sandy Keefe is a regular contributor to ADVANCE.