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Weekly Debriefing Reports

 

 

 

 

Mock Page Simulation Program

Mock Page Debriefing Instructor’s Guide

 

Session Objectives

 

Upon completion of this session, participants will be able to describe:

  1. the medical management of typical cases
  2. common communication challenges and discuss potential mitigation of these difficulties.

 

Session Format

The session is designed to be a one-hour, case-based session led by an attending surgeon or senior resident.  The purpose of the session is to debrief each of mock page cases the learners received during the previous week.  Please ensure that every case from the week is discussed.

This session should be in discussion format.  No slide presentation or other materials should be used.  Potential management strategies for each case should be discussed, along with any communication challenges encountered during the pages. 

Please do not duplicate or distribute the cases provided to you.  The cases provided are for instructor use only. 

 

Questions for Facilitating Discussion

 

The following is a list of potential questions to facilitate discussion.  This list is intended to be a guide for facilitation, and is not intended to be exhaustive or required.

 

  1. What is the primary reason the nurse was paging you in this case?
  2. What is the differential diagnosis for that complaint?
  3. What additional information is required to make the final diagnosis?
  4. What tests and studies are needed to make that diagnosis?
  5. What treatments should be instituted immediately?
  6. What treatments will be initiated in the near future?
  7. If the senior resident, chief or attending should be contacted regarding this issue, when and how should they be contacted (i.e. immediately, sometime today, by e-mail)?
  8. What communication challenges, if any, were present in this case?
  9. What management strategies might be used to mitigate a communication challenge?
  10. What did you do to foster a sense of teamwork between you and the nurse?
  11. How did you ensure that the nurse understood the assessment and plan at the end of the case?

Please contact Maggie Boehler (mboehler@siumed.edu) office  217-545-5145 or cell 618-304-8055 if you have any questions.

 

Case 6:  Transfusion Reaction

 

Case Description: Patient with transfusion reaction. Communication challenge is that the nurse is inexperienced.

 

Nurse Pager gives scenario:  Mrs. Wallace is a 63 year old female who is on the general surgical floor and is post-op day#1 after abdominal surgery. I was just called to the room and she is complaining of chills/shaking so I checked her temperature and it is 39.0 C (102.2 F). I don’t know if this is related to her blood transfusion or what.

 

Two units of PRBC were ordered but you do not know the prior Hgb/Hct.

You started the first unit of blood about 15 mins prior to call. You have to go to get the patient information such as I/O and vitals if they ask because you have left everything in the patient’s room and all of the computer stations are busy.

If asked what type of surgery etc. State the nurse that was taking care of her left due to illness and you did not get a report except that blood needed to be started.

If asked for current vital signs state that all you did was take the temperature since she was complaining of chills. After they ask you to get the current vital signs you can give results.

If queried re: blood checking, state it was done appropriately.

 

Actor cues:

Early in scenario respond, “This is the first time I’ve ever done this.”

Near end of scenario, if learner does not stop blood, check match, or recognize seriousness of transfusion reaction ask, “Should I be worried?”

If queried, the following relevant information should be provided:

Vitals
Prior to starting blood
BP 104/76 HR 94 RR16 Temp 37.5C (99.5F.)
Current Vitals only if asked specifically
BP 90/40 HR 120 RR24 Temp 39 C (102.2 F)
If asked SaO2=92%
Wt 104 kg Ht 5ft 3 in

Assessment
Anxious and pt states she feels like something is going very wrong. Also complaining of back/flank pain
Skin warm, moist with flushed face
Lungs clear
HR regular rate and rhythm
Pulses present bilateral
Abdomen soft non-tender, bowel sounds absent
Wound – dressing clean dry and intact
Previous Hgb/Hct from this AM 6.5/19

I/O
24 hr 3600cc IVF 1400cc urine
8 hr 1200 cc IVF 450 cc urine

You did notice that the urine in the foley catheter has turned a very dark amber almost brown color. The urine in the bag is clear amber

 

Current Meds
LR 150cc/hr
Lovenox (Enoxaparin) 40 mg SQ daily
Morphine PCA 1mg/ml concentration. PCA dose 2 mg with 10 min lockout, 4 hour limit 48 mg.
Taking on average 4 mg/hr

 

 

Summary of Student Performance – Case #6

 

Must Do

Done

Not Done

Ask for vital signs

12

1

Ask for assessment

12

1

Proceed to bedside immediately

12

1

Stop blood transfusion immediately

12

1

Start fluid bolus NS or LR

8

5

Oxygen titrate to keep Sao2>94%

9

4

Transfer to ICU/Rapid Response Team

4

9

Return blood to blood bank to determine if correct blood was administered

1

12

Call senior or chief immediately

12

1

Read-back (closed loop communication)

11

2

 

 

 

Should Do

 

 

Lasix 20-40 mg IV titrate to maintain Urine output

0

13

Repeat blood type and crossmatch

0

13

 

 

 

Could Do

 

 

CMP or BMP

2

11

Portable Chest Xray

4

9

Hgb/Hct

4

9

Solu-medrol 125-250mg IV loading dose;followed by 0.5-1mg/kg q6h for up to 5 doses

0

13

Once in ICU, start pressor (dopamine, phenylephrine, or norepinephrine) titrate to keep SBP>100

0

13

Tylenol – 650 mg

2

11

Benadryl – 50 mg IV

2

11

Blood culture

3

10

Urine culture

4

9

 

 

 

Mustn’t Do – please note “not doing” these are correct

 

 

Send patient off floor for PA and Lateral

0

13

Ephinephrine IV

0

13