Simulation report 4/4/24, In situ sim ED JHC

 

Hi everyone,

 

Thank you so much for participating and helping in last weeks sim. I hope we all enjoyed the scenario.

In order to share our learning goals, I have formulated a sim report.

 

As per usual this report is not about what the team did or didn’t do but about formulation of general learning goals and outcomes of the sim to improve our quality of care and interdisciplinary cooperation.

 

 

Our case:

 

25 y o Sarah self presented to ED with Abdominal pain for around 12h. It increased this morning so she decided to get checked out.

At triage she acutely deteriorates, vomits and passes out.

The emergency bell was rung and she was escalated into the ED as a priority 1.

In Resus she was found to be hypotensive, tachycardic and drowsy. An efast confirmed large amount of free fluid and ectopic pregnancy was established as the most likely diagnosis. Unfortunately theatre and staff was not accessable at the time, so that the focus went on resucitation of the patient. Blood products were administered as per MHP and a clot pro assisted in identifying correct product choice.

After 30 min theatre was available so the sim was finished.

 

Our learning goals in this case:

 

1.Response to a walk in Cat 1

 imediate escalation with emergency bell

 large number of staff present usually,

keep minimal but later stay open minded for increasing staff requirement

 resus space often not available, time delays likely

 

2. Rapid Team formation

 team formation difficult in these situations as no preplanning time

 clear communication to establish enough staff present but observers

kept at minimum to simplify situation and keep noise level down

 

3. Rapid disposition planning

 clearly life -threatening situation that is unlikely to be rectified in ED

 establishment of leading differential diagnosis so that disposition can be escalated to correct team

 Laboratory findings such as HB or bHCG have no relevance in situations like this, HB might be factitiously normal as redistribution has not yet taken place and bHCG takes too long to be awaited for.  Lactate only one initially important biochemistry marker to guide resuscitation appropriately

 a  non trauma young female patient with a positive e fast is an ectopic pregnancy until proven otherwise via laparotomy.

 usual disposition not available, think outside frame  transfer?  plan early as takes longer to mobilize resources in foreign hospital

 

4. Focus on what can we do????!!!!!

 focus on resuscitation and continuous review of resuscitation effort if theatre delayed

 Lactate reduction, Temp and Ca important parameters to guide resucitation and    product transfusion

 

5. Review of the MHP and Clot pro in ED

 MHP activation via 3155

 4 Units Oneg immediately available

 1g fibrinogen available immediately

 2 Units of FFP thawing (30min defrost)

 Cryoprecipitate on request (20 min defrost time, consider early)

 platelets considered (long wait time as from RPH Blood Bank)

 

 Interpretation of Clotpro

 complex to interpret during resus, pics over Computer in Resus

 consider team member solemnly in charge of transfusion

 when MHP activated a transfusion nurse will attend in office hours

 after hours consider extra medical staff or senior nursing staff to resus

 

Take home messages

Transfusion is complex!!!!!!

 

Further reading

Sharepoint blood management, table for MHP and clotpro interpretation available

https://www.haemoview.com.au/clotprointerpretation