● Situational awareness : As the leader, Sarah needed to be aware of a lot of information. She needed to free herself from task completion which distracted her from noticing changes in the situation and adapting as needed to ensure safety on the unit. An actual fire in a health care institution is a low volume high acuity event. All staff should participate in drills and review their role in such an event. Jo turns the defibrillator to manual mode and asks the MD leader: “How much do you want me to set the defibrillator for?” MD leader : “200 joules. Pharmacy and Theresa can you prepare 1 mg of epinephrine (1 mg/10mL) for IV push?” I also want to prepare a dose of Amiodarone. Jo : “Defibrillator is ready to deliver. Do you want me to proceed?” MD leader : “Yes, clear the patient and deliver the shock.” Jo (delivers shock): “Clear please, shock was delivered.” Liz documents the time of shock. MD leader (to med student): “Please continue compressions.” The nursing supervisor arrives and states that she will work on obtaining an ICU bed. The anesthesiologist and respiratory therapist are having a whispered discussion at the head of the bed. The anesthesiologist is having trouble seeing the vocal cords and placing the endotracheal tube. He is getting ready to make a third attempt. The RT ventilates the patient between attempts. The MD leader notices that there is a conversation between the two and asks the RT if there is a problem. The anesthesiologist then states that he is having difficulty securing an airway. The MD leader asks RT to continue bag mask ventilations after clarifying that bag mask ventilations are effective. The leader then asks the ICU MD if he would be able to attempt to intubate the patient if needed, should resuscitation continue. The ICU MD responds that he can attempt if needed. The pharmacist and Theresa are also having a conversation at the code cart on the dose of epinephrine. They refer to the guidelines of ACLS medications located on the crash cart for dosing. The pharmacist then prepares the epinephrine bristojet for administration. The pharmacist hands the prepared epinephrine to Theresa stating that it is 1mg in 10 ml for IV push. Theresa then states that she has 1 mg of 1mg/10mL epinephrine ready to administer. MD states to administer the epinephrine dose. Theresa administers, and states “epinephrine 1 mg administered.” Liz documents the time administered. One and half more minutes pass. The MD leader asks the compressor to pause and assesses the cardiac rhythm. “There is return of spontaneous circulation evidenced by a pulse,” states the MD on pulse. Rhythm is stated to be bradycardia at a rate of 50. The MD leader then says, “Let’s stabilize and see if we can get this patient into the ICU.” Question What examples of communication were demonstrated in this case study? Discussion Communication techniques demonstrated: ● Closed-loop communication : This was effectively demonstrated throughout the case study. The MD leader, Pharmacist and Theresa demonstrated this during the entire process of epinephrine preparation and administration. It was also demonstrated in the defibrillation sequence when the MD leader was in communication with Jo. ● State of the union : The MD leader used this technique to summarize the situation after members of the response team arrived and the anesthesiologist inquired about what was occurring. In addition, the MD leader included an ask from the team for additional input. Later in the case study, the MD leader again summarized a brief statement of current situation and what the plans were going forward.
her response. Also, how to activate help for a fire, by locating and pulling the fire alarm. ○ Human resources : Sarah did not immediately call for the internal human resource available to her – the nursing supervisor who has expertise to help her make decisions. Case study #2 Theresa is a nurse on a medical surgical unit in a community hospital. She has been a nurse for over three years and only recently started working at this hospital. She has been trained in BLS and ACLS. She is working with three other nurses and two nursing assistants. On this weekend day shift, the hospitalist just arrived on the unit to see a patient that Theresa’s coworker, Liz, is worried about. Liz’s patient is an elderly woman with pneumonia and heart disease. She has had increased work of breathing and her oxygen saturation has dropped to 90% on 2 liters by nasal cannula. Before the physician gets to the room, Liz calls out that her patient is unresponsive. Theresa tells the unit coordinator to call a code blue and grabs the crash cart on her way to the room. She tells John, the nursing assistant, to remain on the floor and direct the response team to the patient’s room when they arrive, and then to answer any call lights from other patients. When she gets to the room, Liz is performing cardiac compressions and telling the physician that the patient desaturated as low as 68% and was gasping right before she became unresponsive and pulseless. The physician has his ACLS card open in his hand to refer to. He verbally states that he will be in charge, and then asks Theresa to prepare epinephrine and the defibrillator. Theresa tells the other nurse, Jo, to put the backboard under the patient and then place the defibrillator pads on the patient. Some of the responding code team members enter the room (ICU MD, pharmacist, and medical students). The physician leader begins directing code team members. He points to the medical ICU MD and says, “Can you assess the pulse and monitor the heart rhythm as soon as the defibrillation pads are attached?” The ICU MD nods assent. He then points to the first medical student and says, “Can you relieve the RN and continue compressions, changing at least every 2 minutes?” The medical student states he will. The physician then addresses Liz. “Liz, can you document please?” Lastly, he speaks to the second medical student. “Can you relieve the other med student as needed in administering compressions?” The respiratory therapist (RT) and anesthesiologist arrive in the room. MD leader : “Can you, Respiratory and Anesthesia, secure the airway and manage ventilation?” RT confirms task assignment heard with a nod at the leader. Anesthesiologist : “What is the patient history and situation?” MD leader : “The patient is 80 years old with worsening respiratory distress and became unresponsive and pulseless. Compressions were started. We are approaching 2 minutes. We will assess rhythm and defibrillate if necessary and administer epinephrine. Does anyone have anything to add?” No one adds anything. Jo places pads on the patient and turns on the defibrillator. MD leader : “Two minutes. Let’s pause compressions and switch compressors.” MD leader (speaking to the ICU MD monitoring the patient’s pulse): “Is there is a pulse?” ICU MD : “There is still no pulse.” MD leader (looking at the defibrillator screen): “The rhythm indicates VF. Please prepare to defibrillate. Resume compressions.”
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Book Code: ANCCUS2423
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