[Marge] Hello, everybody.
I know that,
can you guys hear me?
Yes.
Yeah, we can hear you.
Hi.
[Marge] I am sure that you guys were all ready to go,
but I feel the need to introduce,
well, everybody knows Julie Parent,
and so it's lovely to have her here,
since Sam insisted on taking time
to spend with her new baby, I don't know why.
Soon that should be waiting though.
And but I know a lot of you know,
Amelie Thurson, our nurse educator,
she's the one that put the awesome drill books together.
And then you might not know, but should know Wendy Conway,
who is one of the OBGYNs in our practice,
she's now the head of our QA&I,
she's our night hospitalist,
she is a great wealth of information.
She has a special interest in simulation,
and has worked with Kelly and Amelie
in terms of rolling out the Insight to Drills,
or whatever it is that you wanna call them.
So, I just wanna thank them so much for doing this,
and I am happy to turn it over.
Thanks.
Thanks, Marge.
All right so, good to get going, Julie?
Yeah.
All right.
Thank you guys for joining us today.
As Marge said, we're gonna talk about the drill books
that we've developed over the last year or so.
I presented the drill books at the Nequin Conference,
and there was a lot of interest
in having a little bit more like detailed explanation
of how we really like implemented it,
and how we run them on the floor.
So Wendy and I are here today
to talk to you guys about how we've tackled this
at UVM Medical Center.
We have no disclosures to share with you all.
Wendy's gonna introduce herself.
I'll just briefly, as Marge said,
I'm the Nurse Educator on Labor and Delivery here at UVM.
I've worked in this role for the past five years,
and was a staff nurse on the floor
for 10 years prior to that,
and definitely did not have a lot of experience
with simulations and drills
when I stepped into the educator role,
and very quickly felt like I was like,
a little in over my head.
But luckily have had a lot of opportunities for training
while I've been in this role.
Hi, I'm Wendy Conway.
I was asked to jump in on this,
just mainly because of the experience I have
with simulation.
But I, like Marge said,
I'm a generalist and a hospitalist
that works now at the University of Vermont Medical Center.
After I left, I actually did my training at UVM in OBGYN,
and then left, and was a veteran,
and served on active duty for the Air Force
and was stationed in Japan,
on a very small military base where I learned a lot,
and then was sent to a very large overseas military base
in Germany, called Landstuhl Regional Medical Center.
And we were the only level one trauma at that time,
certified,
and we were the Obstetrical Regional Transport Center
for Europe.
I also have experience
working in a lot of smaller hospitals throughout Vermont.
I did not immediately work for
the University of Vermont Medical Center when I came back,
when I was finished with my active duty,
my military commitment.
So I do have a lot of experience,
and kind of know what it's like to be in a small hospital
with much more limited resources.
And most recently,
I started working with Society for Maternal Fetal Medicine,
they have a Critical Care and Obstetrics course,
which I highly recommend
if you're interested in doing any kind of simulation,
it's a great conference.
In Arizona, they have an entire hospital
dedicated to just simulation,
and there's a course that we run there
that runs through several things.
But I'm specifically trained by them to be a debriefer,
so my role isn't to necessarily run the simulation,
it's more to talk about what happened during the simulation,
how everyone's feeling about it,
and get people to talk about it, and open it up,
and make it as non-threatening as possible.
And I really want sim to be
really non-threatening for everyone,
because I think the more you do things,
the more you think about things,
and the less threatened you are,
and unafraid to ask questions,
because every facility location, everything's different,
it will only improve patient care.
But thank you.
So I'm just gonna talk, just like super high level,
very brief overview of what AIM is,
in case some of you are not familiar.
AIM is the Alliance for Innovation on Maternal Health,
and so this is like a national organization
that carries out its work on the state-based level.
It's a quality improvement initiative
to support best practices and make birth safer,
improved maternal health outcomes,
and ultimately, save lives.
So as I said, it says you implement these AIM initiatives
on a state level.
So, based on a review of like our hospital's data,
and requirements also from the Joint Commission,
UVM Medical Center chose to focus on the
Hypertension Obstetric Hemorrhage Patient Safety Bundles,
and AIM creates the bundle for you.
So it's a really, really excellent program to work with,
because there's no recreating the wheel,
all of the resources that you need are on their website,
and like very, very user-friendly.
So, you know,
there's lots of different patient safety bundles
that are available, and I'll show you some of those.
But we focused on these,
because the Joint Commission has a requirement
that all staff and providers
that take care of pregnant patients
are doing annual education on hypertension and hemorrhage.
And then also, our data reflected that these were areas
that would be beneficial for us to focus on too.
So, right now, those are the two topics
that our drill books focus on.
I think that every hospital,
every hospital now has a copy of our drill binders,
but that doesn't mean you have to start
with those two topics.
You know, if there's other things
that feel more pressing in your environment,
then, by all means, start with the bundles
that feel the most applicable for you.
These are the current AIM safety bundles that are available
on the AIM website.
And once you're on the website,
kind of like click into each one of these,
and it opens up the whole bundle.
But these are the ones that are currently available.
I think they're always working on creating new ones.
So like for example, if you click into
the Obstetric Hemorrhage Patient Safety Bundle,
this is what you'll find.
So, each bundle is broken down into these categories,
these five categories of Readiness,
Recognition and Prevention,
Response, Reporting and Systems Learning,
and then a new section
that is now part of every patient's safety bundle
is this Respectful, Equitable and Supportive Care
for patients.
And then like once you click into each one of these links,
there's more and more information on like,
how to prepare, how to be ready,
how to recognize and prevent,
what's your response.
So it's really nice, 'cause it gives you just a template,
and then you can modify things
for your specific environment,
obviously, depending on the type of hospital that you're at,
some things may not be applicable
or need to be adapted for your practice area.
This is great, 'cause you don't have to reinvent anything,
it's just, print it out and figure out what you wanna use.
So it shouldn't be a lot of work.
And then if you have the binders,
we kind of went through,
and like the binders there,
it gives you an example of what we use
at UVM Medical Center,
and then it also gives you the example
of the one that AIM provides.
So you can kind of see how AIM lays it out for you,
and then you can see how we adapted it for our environment,
and then you can make, you know, similar changes
based on what you need.
So I think a really important step upfront
before you, you know, even try to launch this,
is to make sure that you have
institutional support and buy-in
from the leaders in your area.
It's pretty hard to embed this into the culture on a unit
if it's not what you have previously done.
And then that becomes even more difficult
if you don't have support from your leadership.
So those conversations should kind of start there.
You know,
are we in support of not down staffing
to keep staff on the unit to run drills?
Are we in support of scheduling simulation events
and activities outside of patient care hours?
That kind of stuff.
So those are important conversations to have.
And then from there,
you need to have the conversations of
who's initiating drills,
who runs the drill,
who actually is facilitating,
and who's tracking them.
That might be all one person,
and it might all be separate people.
Again, it depends on like the size of your team,
who is available,
and just how like the workflow will work best for you.
So if you are one of the people
who's going to be facilitating the drills,
I think the most important step, really,
is that you feel prepared
before you start running drills with staff.
Familiarize yourself with the resource binder,
there's tons of information in there.
So then if you can figure out
what's already included in the safety bundles,
and is your organization
already meeting these recommendations,
or do you guys have a lot of work to do
to meet the recommendations?
So first, before you start running drills,
I'd say look at your workflows,
and are you in alignment with the current recommendations,
or do you need to start, you know, a couple steps back,
and adapt some of your workflows
to make sure that you're meeting all of the recommendations?
The other thing is too,
what's critical to understand in doing,
if you're gonna run a drill,
it's hard to be the person both running the drill
and then debriefing and facilitating the drill.
So when we're at these conferences,
a lot of times what happens
is there's someone actually running the drill,
and being the patient,
and saying what's going on,
and then there's someone kind of watching to debrief later,
to talk about how it went,
and what we could do better,
or was there any confusion.
It's hard to be those two people at once.
So a lot of times this has to be
a kind of combined tag team with someone else in mind,
and it can change varying on the day that goes on.
But it's a big task to take both on it once,
unless you really feel comfortable in that,
whatever you're running,
that you feel comfortable
kind of debriefing and facilitating,
at the same time and you feel comfortable with your staff.
Just know that having a buddy can help in this situation.
So a little bit more just in terms of getting,
if you are the facilitator or a co-facilitator,
you know, before you want to run through scenarios
with folks and have them respond appropriately,
you wanna make sure that you really understand the processes
at your own organization.
So, you know, before you run a postpartum hemorrhage drill,
do you have a mass transfusion policy at your hospital?
If you do, and you don't run them frequently,
really helpful to incorporate
talking through this process in the drill.
But to feel comfortable doing that,
you need to really understand the process yourself.
I know for myself,
you know, the further I get away from the bedside,
the less comfortable I feel with these,
with emergency workflows at the bedside.
I can like certainly speak to them,
but if you want me to be the one to open up Epic
and order the MTP,
like I'll be a little rusty,
'cause I haven't been at the bedside.
So I think, you know,
making sure that you feel really comfortable
speaking to this,
and being able to answer questions
about protocols at your hospital,
will help you feel much more comfortable
jumping into running a drill.
Similarly,
like do you already have a postpartum hemorrhage cart?
Do you know what's in it?
Do you know when it's expected to be used?
Do you know what the process is for weighing.
You know, do you feel comfortable with all of those things?
If you don't,
you should reacclimate yourself with that stuff
before you try to do it in a drill.
Similarly, do you have a virtual postpartum hemorrhage kit
in your Pixis?
Do you know how to access it?
You know, you wanna make sure that you can speak to that,
so that if people have questions,
you're comfortable to answer them on the fly.
Again, debriefing and reporting.
The debriefing is gonna be a huge part of running drills.
I would say the most important part, really, is the debrief,
it's where like, the most learning can take place,
and where the most damage can be done
if you don't address it correctly.
So, again, do you guys have debriefing forms
on your unit already?
Is this a practice that you're used to doing?
If it's not,
if debriefing isn't super routine,
and you don't already have an established process,
I would say, establish one.
We have kind of two different reporting systems,
and it depends on the severity of the event.
But we really encourage folks to be debriefing events
in real time, as close to the incident as possible,
with as many members of the care team as possible.
You know, for things that have poor outcomes,
and for things that go well.
There's no reason you can't debrief something
that had a great outcome,
especially if you wanna call attention
to the things that worked really well,
and that you thought, you know,
excellent teamwork around specific things.
Definitely call that out.
Debriefs don't have to just be for bad outcomes
or stressful situations.
But, again, before running the drill,
make sure you understand what your own process is,
and what the expectations are at your hospital now,
and develop a process if there isn't one already in place.
And then, again, in preparation,
the binders come with scenarios.
So, each binder is its own topic.
So there's the hypertension binder,
and the hemorrhage binder.
Each binder has three different scenarios,
so definitely pull the scenarios out and read through them.
I think understanding the objectives for participants,
you know, and what each participant needs
to do or accomplish before this scenario can be complete
is really important.
So, you know,
you don't need to memorize every step of the scenario,
definitely not,
you know, there's checklists, and there's role cards,
and you have the scenario printed out.
They all have like this flow diagram,
so it starts with like, your vital signs at the top,
and like what's going on with the patient,
and it's really like step by step.
So you don't need to memorize it,
but you definitely wanna feel familiar with it.
And then aside from the scenario itself,
like what else are you gonna need
to make this feel more realistic?
And it's totally up to the facilitators,
how realistic do you wanna get with this?
You know, at 5:00 AM it's gonna be a struggle
to get everybody up and participating,
at 5:00 AM, you know, maybe is not the time
to run this super high fidelity, complicated scenario.
Maybe at 5:00 AM is more the time
to just kind of pull people together
and talk through a scenario.
So you can decide how realistic you want it to be,
high fidelity is, it's great,
but it's a lot on the facilitators.
So don't, I would say,
you know, especially when you're starting out,
like don't put a lot of pressure on yourself
to feel like this is perfect.
You know, "I have all of the props,
I have all the stuff,
I have my fake blood, and the fake IV."
It's not necessary
for it to be a meaningful learning experience,
but it does, I think, make it more fun.
So, you know,
if you know when you're gonna do on next Friday
in the middle of the day,
and you wanna get it like super fancy, go for it.
But don't feel like you have to do those things
in order for it to be meaningful.
But, you know --
Yeah.
Sorry, Amelie.
Go ahead.
I think it's important to know
that if it feels like a hurdle
with all the stuff to run the drill,
then don't worry about the stuff.
And I know at night it's really difficult to plan sometimes
to do a simulation, because the census to the board,
and the staff, and what's going on.
And if you just can't get the stuff together,
but you wanna run a quick drill over something,
then do it, and make it fun,
maybe hand out little index cards
that says you're the resident, you're the nurse,
you know, and make it fun that way.
But make it as easy as possible,
and make it fun for everyone.
And not everyone's supposed to know everything,
it's supposed to be a group learning experience
that everyone's there to enjoy, I guess, in a way.
[Marge] I just put in the chat,
it's not a test, feel free to cheat.
We gave you a ton of stuff to cheat from,
feel free to let everybody cheat,
make sure that the nurses have available
everything that they need to cheat.
The idea is for people to know and develop muscle memory.
And I can't emphasize what Wendy said enough,
you make this,
we develop these to make them as low barrier
as you wanna do 'em,
and I would 100% recommend you start
with the lowest level of barriers,
to just talk through the scenarios as you can.
The important thing is to do them, rather than not do them.
Absolutely.
So for ours, like here at our hospital,
we have the binders out,
and then with each binder,
there's like a little kit of supplies.
For the hypertension,
it's very minimal stuff that's required,
so I just have like a little envelope,
plastic envelope that goes right in the binder,
a three ring, you know, envelope,
and it has like these,
I have printed out fake files of meds,
and just printed them in color,
and then laminated them.
So you know, if somebody's going to grab hydralazine,
they're just getting a little laminated picture
of hydralazine.
You know, people don't need to be pulling real meds,
we don't need to be drawing medications up
unless you feel like that would actually be helpful.
I mean maybe you don't have hypertensive crises
frequently on your unit,
and maybe it would be helpful to review the dosing,
to review the volume.
If you feel like that's helpful for you,
then totally do that.
Some other places, like we do it a lot with real patients,
so for us it doesn't feel like we need to practice
with actually drawing up medications.
And again, like if you're planning ahead of time,
if you're gonna have,
some places have like these high fidelity mannequins
that can have postpartum hemorrhages,
and that is great if you have it,
and you know how to use it,
and you want to,
but you can also like pull a nurse off the postpartum unit.
Or you know, I think it's helpful to not use someone
that they see all the time,
'cause that like immediately makes it not very realistic.
But it's nice to have a real person,
'cause they can interact,
you know, they can answer questions,
it makes it feel a little bit more realistic.
But again, if you have everything you need to run a drill,
but you don't have a person to be the patient,
then just go for it anyway,
and just talk through what's happening with the patient.
We also have like, just pictures of blood products,
again, that I just laminated.
So you know, if people are calling for blood products,
you can go step by step through the whole ordering process
if that's what you wanna focus on.
Sometimes, like, that's what really needs to be practiced
and talked through,
like what's the best way
to get blood products up here quickly.
That could be the focus of your postpartum hemorrhage drill.
It really needs to be catered
to what you feel like is the most helpful thing
for you to review.
For my nursing education days this year,
we're gonna do a postpartum hemorrhage scenario,
and we just implemented
A1's postpartum hemorrhage risk assessment tool
and embedded it into our electronic medical record,
so a big part of our simulation
is gonna be talking about the tool,
and how to do correct documentation
so that the tool works correctly
and we have accurate risk assessments on our patients.
So it's like, you know, focus on what you need to focus on
and where you see the gaps for folks,
and that could just be with the basics of response,
or it could be to these more like little nuanced things
that are specific to you.
And so kind of like I was saying before in preparation,
develop your resources.
Do you already have an algorithm
for hypertensive crisis IV medication administration?
If you already have an algorithm,
use that algorithm in your drills.
Like Marge was saying, this is not a test.
You want people to know what their resources are,
you want them to know where they are,
when to use them, how to use them.
So I encourage people,
you know, pull that algorithm right down off the wall,
and put it at the bedside, and use it.
You know, you don't need to memorize the dosing,
you need to know where the algorithm is
and you need to refer to it.
So if you don't have an algorithm,
you know, AIM has examples,
we shared an example,
you can either just use theirs, or you can develop your own.
if you don't have a postpartum hemorrhage cart,
again, we gave you an example of ours and what's in it,
you know, create one,
and the drill can really be around
the postpartum hemorrhage cart and how to use it,
if that's new for your area.
All right, so once you, as the facilitator, you know,
once you've decided who is facilitating these drills,
who's responsible for making sure that they're happening,
for us, you know, we really wanted,
I think our biggest focus
was empowering the folks who are working on the floor
to run drills when it's most appropriate
to run a drill on the floor.
It's great if you have leaders, educator, manager,
you know, clinical nurse specialists,
who want to schedule these things in advance,
and facilitate them.
And you know, we do do four hours, eight hours a year
of interdisciplinary drills in the UVM Sim Lab,
you know, that's very different.
But we wanted people to feel comfortable saying,
"You know what, it's low census,
I'm about to downstaff a nurse or two,
and like, I wanna run a drill right now."
So our model is that our attending,
we call 'em the 7OE,
it's like the hospitalist who's covering for the day,
they are kind of responsible
for identifying moments on the unit
that seem appropriate to run a drill.
And then collaborating with the charge nurse
to run it together.
Certainly a charge nurse could say,
"Oh, you know, hey Dr. Conway,
I'm about to downstaff two nurses.
Are you in a good place to run a drill first
before I do that?"
But also, you know,
totally appropriate for the provider to come out and say,
"You know, is there anything going on that I'm not aware of?
Let's run a drill."
As Wendy was saying, you know,
really, really, I think, very critical
to have two people who are participating.
You have one person who's,
you know, making sure you have all the equipment,
making sure, logistically,
that you have stuff that you need,
and they'll probably be kind of like,
you know, the mole in the room.
If they need information, you're providing it.
If they don't understand something or need to be redirected,
you're the one who's doing it.
Then you have another facilitator
who is more observing, taking notes,
and is gonna be really prepared to provide feedback
at the end of the scenario.
Again, it's open book,
this isn't a test.
So there's checklists, grab the checklist.
You know, you don't have to memorize all the steps
for what an anesthesiologist, or an OB resident, or a nurse,
needs to do,
what you need to know is where your resources are.
And one more thing on the debrief.
So one of the things we're trained at,
you know, this group of debriefers
comes from across the country to sit,
and we take, basically we get a long discussion
on how to debrief in language.
And what's really important and take home in that,
what I've been trained
through the Society for Maternal Fetal Medicine
is that the debrief is not to be threatening,
it's not to make anyone feel bad,
and it's mainly meant to make everyone talk,
and feel heard and understood.
And if something's missed, it's not a big deal,
not a big deal.
And language of, you know,
"Well, what could you have done better?"
Not good for debriefing. (laughs)
You know, say things like,
"hey, that seemed like it was fun for you guys,"
or "how did you feel about that?"
or "is there anything in particular you wanna talk about?"
You know, something very open-ended and non-threatening
to get everyone talking,
and the goal of the debriefer
is to get everyone to discuss
what they felt was happening,
and any small point they were confused about,
not to necessarily drill in a point
that they missed a dosing, or a step.
And if they did, talk about it.
You know, what happens here?
What do we know about this?
Have guidelines changed?
I don't know.
I feel like guidelines change every five minutes,
and sometimes I have to look stuff up again,
and relearn it differently.
So I think that that's important to say,
no matter your experience base, it's important to say,
"Gosh, that's changed and I didn't know that,"
or "I hear you,
and let's talk about why you thought that way,"
but never to make anyone feel like they did something wrong
per se.
Totally.
So for the pre-brief, I've definitely found
that it's very, very helpful to prepare people for this.
Like, nobody loves to be caught off guard,
nobody wants to be like in the spotlight feeling unprepared.
So I think, you know, tell people,
"We're gonna run a drill,
it's gonna be on on postpartum hemorrhage.
These are role cards.
These are your responsibilities in this drill.
This is what's expected of you."
I think people feel much more comfortable
when it's all laid out ahead of time.
And I've also like, if you don't explain things too much,
it just leads to confusion.
Like there's definitely been times where they're like,
not clear like what the facilitators are there for,
if they can ask facilitators,
you know, like, is this facilitator participating?
Or you know, just be really, really clear
so everyone knows what everyone's doing,
what everybody's responsibilities are.
Like name tags are helpful,
you know, not your name, but your role,
so you know, nurse, resident,
depends on who's part of your team.
But it has helped,
and definitely a facilitator role,
because people are gonna be like walking in to the scenario,
you know, they hit the call light,
someone new comes in, they might not know what's going on.
Like they can see Amelie and Wendy are the facilitators,
so like they're not asking us to, you know,
go page anesthesia.
And again, sharing the details of the patient's case
with the primary nurse prior to her entering the room.
So, you know, helping people to
just feel like they know what they're walking into.
You know, the technique of like,
we'll just hit a call light and have them come,
it just leads to a lot of confusion,
and people feel insecure and like unsure
about what they're supposed to do.
And then there's like, okay,
and I know that's not really a patient,
because that's a nurse from across the hall.
So then there's like,
like that they're a little like laughing,
and they're not quite sure.
So I just think like setting the expectations
from the get-go,
it just helps people to also participate and engage,
and not feel like,
"Oh, okay, this is funny, and this is weird."
You know, they're like,
"Okay, I know what we're doing,
and I'm ready for it."
The debrief form, like I said,
if you have one that you already use, you should use it.
So what I've been doing with folks is,
after running a drill,
I have that that group that participated in the drill
debrief themselves like they would after a real event.
So there's like,
they debrief themselves using the debrief tool that we use
for real events,
and then once they're kind of finished debriefing themselves
as the debriefer,
then I, you know, get into a larger,
kind of next level debrief with the whole group,
and then incorporate the things
that the facilitators observed,
and the feedback that we wanna share.
And sometimes the group has already kind of covered
everything that you were gonna talk about.
And sometimes, depending on the group,
sometimes the facilitators really need to like,
pull it outta people and get them to open up.
You know, if it's a brand new crew,
this is the first time they've done it,
and they're just like feeling really unsure
about everything,
it might take a lot more like coaxing
to get them to open up and talk about it.
And if it's people who have done this already
a bunch of bazillion times on an actual patient,
they might just kind of,
you know, zip right through the debrief
and feel pretty good about it.
And then also, you need to develop a way to track
the drills that you do.
Especially when the Joint Commission comes around,
they wanna see who participated
in these different types of events
and what kind of education are people getting.
So, very helpful to have a log.
Again, there's an example in the binders
of the ones that we use,
just really simple and straightforward,
like the date, the location,
the topic of the scenario,
and who participated, and who facilitated.
We keep the log,
there's paper copies of the log in the drill books,
so you can just fill it out right there.
And then I just ask people to put it in my mailbox
right outside my office.
And then there's an electronic copy of this as well
in a shared location,
so we have it on our team's channel
so that like multiple people can access it
and update it as well.
But ultimately, I'm kind of responsible for tracking things,
and then I report to Sam Bellinger, like kind of quarterly,
on our drills, and give her copies of our log sheets.
And then incentives,
like Wendy was saying,
like any way to make it fun,
any way to make people excited about participating.
You know, it has not historically been the culture
on our unit at UVM to run a lot of drills,
especially on the unit.
I think we have done a better job about,
you know, having activities in the sim lab,
but to really run these in SISU drills
in the environment where you're taking care of patients,
it's not something that we are used to.
So, you know,
it takes a while to embed things into the culture,
and I think, in that process,
the more that you can incentivize and make it fun,
or everybody who participated at the end of the year,
you'll get put into a raffle
that we'll draw at the end of the year,
and someone will win a prize
just for participating in the drill.
So, stuff like that makes people, hopefully,
like not run the other direction
when they see you coming with the drill binder,
because that is often what happens, you know?
I think the more people participate,
the more they do it, they start to feel more comfortable
and like it's less intimidating.
[Marge] And just so you know, I put it in the chat,
we have a budget for prizes.
And Sam and I, I don't know,
if you guys have ideas of it,
we're happy to,
we wanted to do gift cards,
but it was weird, we couldn't,
there was tax things, I don't know, it was all weird stuff.
So we're still working on that,
just so that you know.
But Sam is way more creative than me, and she's on it.
Hey, Marge,
do you know what I've done in the past at other facilities?
I don't know if it's allowed, don't get mad at me,
but I've done little $1 scratch off raffle tickets,
or you know, lottery tickets.
Lottery tickets?
[Marge] Oh yeah, yeah.
I can't remember.
Because it's federal money, 'cause we --
Yeah, it's like,
I bought my them myself just to like, make people --
[Marge] And I told Sam I was willing to do that too.
Less angsty about it, in lottery tickets.
[Marge] It's still on the table. (laughs)
Yeah.
You know?
Yeah.
So I think we can just open it up to questions.
Like what do you guys wanna know?
Can I add one more thing,
so when we have an event happen, bad or good,
just an example,
we had a shoulder dystocia a couple months ago,
and I know all of you probably have
new travelers on your floor,
constructions happen on floor, things change,
and during the shoulder,
I turn to the new traveler nurse at night,
and I said "mark time,"
and she couldn't find a clock.
The clock on the wall had been taken down,
and she didn't know where the clock was on the computer,
and I needed every 30 second interval called out,
and when she wasn't doing that,
another nurse figured out what was happening and took over.
But that's one of the things we talked about,
like what happened there during that.
She's like, "I couldn't find a clock!"
And so, that's an easy time to debrief,
like a shoulder dystocia.
What happens?
What are the first maneuvers?
Where are you gonna mark time?
Where's pediatrics gonna go?
And so it was super easy to do a quick drill after the fact,
when everyone was really jazzed up
and wanted to talk about it.
Now, you don't have always have time,
but that's a way to run a fast drill
with realtime feedback.
And then, you know,
we already have people asking for other topics.
You know, you can only run so many postpartum hemorrhage
and hypertension drills
before people wanna start seeing other stuff.
So, we'll be developing new scenarios, I think.
I think we're gonna focus on these two for 2023,
because we really just need to like,
I keep saying, embed this into our culture.
So we're gonna focus on these two topics,
and then we'll start to build from there,
kind of depending on what we'd identify
as the biggest needs for us.
And I know some of the smaller hospitals in Vermont,
the units sometimes can be way understaffed,
you know, if you have one nurse.
Or you can also run a drill that says,
if you have one nurse on the floor,
and say someone comes in for a labor check,
and your patient that delivered yesterday
has a delayed postpartum hemorrhage, what are you gonna do?
Having been in the situation with one nurse on the floor,
I asked for a rapid response team.
They didn't have that at that facility,
so then we called the ER.
And I've never seen so many excited people
happy to start IVs in my life.
But that's another fun thing
you could do with a smaller hospital,
is maybe do a joint drill
with your emergency room department,
or you know, whoever you have after hours,
when maybe your staffing is very low.
[Kathleen] Hello, my name is Kathleen,
and this is absolutely wonderful and very helpful
for something I'm planning on doing
as a public health person.
So, this is wonderful.
My question is,
what would you say your biggest barriers
to the rollout process was
that you had in the beginning,
or that you still find?
I know that you mentioned that,
and I was a bedside nurse for a long time, yes,
very, very much resistance,
and "Nope, I don't wanna do that.
Nope. Nope. I might need to act busy."
But how about outside of that?
What barriers would you say to expect?
Well, initially when we first rolled this out,
we tried to schedule things,
you know, not with the staff per se,
but like the facilitators would try to schedule it
ahead of time based on our availability,
who's on call when, and who's available when.
And that really did not work very well at all.
I mean, it was like every single time we had a drill,
that just guarantees that the unit is exploding
and that we have four call outs.
So we stopped doing that pretty quickly,
And, you know, we still occasionally will try, I'll say,
"Oh, next Wednesday I'll come in for an evening shift,
and we'll try to run one on the night shift."
But I would say it's this,
it's like the identifying the appropriate times,
and then somehow empowering the people who are there
to feel comfortable to do it.
You know, when you have a provider like Wendy on,
I think it's easier, 'cause she's very comfortable,
and more than willing to grab the team and just,
you know, kind of be like,
"All right, this is what we're doing."
You know?
But if you have providers
that haven't run simulations themselves,
with a charge nurse who's brand new
and doesn't feel super comfortable,
it's, you know,
I think our challenge is like holding people accountable
to make them happen.
Yeah, it's, I agree with Amelie,
it's the human factor, right?
You show up,
you know, people have called out,
people are sick, people are grumpy,
and the floor's going crazy,
and you just can't run a drill.
But if you have someone who says, you know,
if you pick a couple of drill people in your department,
and really sit with them and train them
till they feel comfortable.
I think starting there,
like get the drillers together,
and maybe run a couple drills together as the group,
talk about that.
And then when I show up on the floor,
I look around and I say,
"Okay, is tonight gonna be a good night for a drill?
Do I think I'm gonna be able to squeeze one in
somewhere here?"
Or does the staffing look good?
How many patients do we have showing up?
Kind of like, flexibility,
I think the human element, and flexibility,
and showing up and saying,
"Okay, am I gonna be able to pull this off tonight?"
Are the two biggest hurdles.
It's not the information, we all like it,
I mean we all love this stuff,
or we wouldn't be doing what we do,
but it's more the ability,
the extra energy to do what you have to do
on top of what you already have to do
that can get to some people.
Yeah, and like for us,
I'm sure similar to other hospitals,
our night shift are generally our newer nurses
and our travelers,
so that's the shift that needs this the most.
And but like, I don't work night shift,
and other leaders in the department
are not around as much at night,
and it's certainly not at 2:00 AM
when you are like, "Oh, now would be a good time."
You know?
Sometimes I work until 11:00 PM,
but I generally, unless there's a huge crisis going on,
I'm not here in the middle of the night shift.
So I think, really,
the challenge is getting people to feel comfortable enough.
And I think what Wendy's saying,
like have the people who are the facilitators
practice with each other first
before they do them with staff nurses.
It's very understandable,
you wanna feel like very credible with your nursing staff.
You know, you wanna feel like you can speak to all of it,
and you're super well organized,
and you're like doing this awesome activity.
I think like lowering the bar for yourself a little bit,
and saying, you know what,
just getting out there talking through stuff,
you know, creating some checklists, as we don't have them.
There's a lot of things that you can do to support this
without feeling like I, personally,
have to be the one to run every single one of these drills.
And I think another fun point is that if you,
if we run the drills for conferences,
we give everyone an assignment.
So, someone's pediatric, someone's anesthesia,
someone's resident one,
someone's nurse, and someone's attending.
And if you have that many people,
you know what I'm saying,
you could certainly assign people roles.
But what what I found was very educational
for physicians in particular, is when three physicians
are giving one nurse orders. (laughs)
And I say, "Yeah, it's not fun, right?
You need to realize
that she can only process so many things at once."
And so that was a good part of the simulation,
to say, you know, that's too much for one person
and they're overwhelmed,
what do we need to do to help them do this better?
That can be also a part of your simulation.
It was very educational,
especially for some of the residents,
to realize how hard it's for a nurse
to take that many orders at once
with that many people talking at them at once.
Yeah, like sometimes the focus of the drill,
it's a postpartum hemorrhage scenario,
but like what I'm honing in on is team communication.
You know, I wanna see closed-loop communication.
And like so that might be
what I am choosing to focus on for the debrief.
And you can let them know ahead of time, you know,
we've been having a lot of issues around communication,
you know, if you see a slew of safe reports,
and communication seems to be a topic,
like make that a more central focus of your drills.
You know, you can really adapt the scenarios
to really meet the needs
of what's going on in your unit right now.
And be creative, be fun, you know?
Involve other units.
Make the pediatrician be the anesthesiologist,
or make someone be the pediatrician.
You know?
Your pediatric team can't get there for 25 minutes,
who's gonna resuscitate the baby?
Who feels comfortable doing that?
These are things that you can learn about each other,
just chat.
Like say, you know, "I would rather boil myself in oil."
But some people might say,
"Oh, I have tons of NICU experience, so I'll do that."
You know, that's a good resource then for them later to say,
"Hey, you've done this before, can we talk about this?"
So that you learn more about each other in these drills,
as well which can really help patient care moving forward.
Yeah, so I also, I teach NRP,
and in the NRP simulation world, at least here,
you know, you can have a class of 10 people,
and they all might be nurses,
or half nurses and half respiratory therapists,
but you still have to resuscitate a 24 weeker, so.
But you don't have your neonatologists,
and you don't have the people you would have in real life.
So in NRP scenarios, I think it's really, really common
that you're acting outside of your role,
and you're doing things
that you would not be doing in a real life scenario.
I try to avoid that, you know, whenever possible.
Running drills on the floor,
you have everybody there, we do,
obviously in community hospitals,
it might not be the same way.
But we have the members of our team,
so I have people do what they would do in the actual,
you know, real clinical environment.
I don't think, personally,
I don't think it's super helpful
to have people practicing stuff
that they actually aren't responsible for,
but I do think conversations around it,
understanding other people's skillsets,
and understanding the responsibility
of the other people on the team is super, super important.
[Marge] So, this is Marge,
did you guys talk about the question in the chat from Andrea
about JAYCO?
Oh, no, I haven't even been looking at the --
[Marge] Okay, I just was wanted to address it.
I didn't think you did,
but I had to take a phone call,
so I might have missed something.
I see, yeah, so this --
[Marge] What you need to do for JAYCO,
you do need to prove your education
every two years for JAYCO, for hemorrhage and hypertension.
That's the cornerstone.
That is Amelie's other favorite project,
I know since we worked on it for like three years.
The fact that you have drills is required by JAYCO,
but you don't have to document
that you have run all of your staff through drills
as an individual at any time.
Does that answer your question, Andrea?
[Andrea] Yes, absolutely.
I was looking at like the prizes and everything,
and I thought those are all great ideas,
and then I'm like,
"Man, like it's just gonna be challenging
to kind of get everyone."
And I was trying to review those standards,
but really appreciate that.
Thank you.
[Marge] Yeah, no way.
I think the main thing is, for all providers,
and just to remind you that, the cornerstone,
which, again, we're happy to share with anybody,
has to be not just for all OB providers,
and I'm talking about docs, midwives, nurses,
it also includes anesthesiology,
and even more complicated,
it includes the emergency room docs and nurses.
That is a big lift.
[Andrea] Right.
And one thing that I've done,
you know, in order to ensure,
like it's impossible to make sure
that every single person participates in a drill,
but I do a drill is not the same as a simulation,
like the terminology,
drill is means it's like on the unit, it's in SISU,
it's in the environment
where you're providing care to patients,
whereas a simulation can happen in a lab,
in a sim lab, or you know, in a conference room.
So all of our nurses on labor and delivery and postpartum,
you know, participate in education days
where we will do one of these topics every other year,
so that like every other year,
they're reviewing postpartum hemorrhage
and hypertension scenarios,
and then everyone also gets the cornerstone module
loaded as well.
Any other questions?
I have not been looking in the chat.
Yes, Leah's top comment is absolutely true.
Like, you can definitely frame these as a way,
you know, it's a way to explore
if there are gaps in your system.
And that really is the true intent,
it's why you are supposed to run them on the unit
using the systems that you actually have in place,
so that you can identify
where there's a glitch in the system,
or where you need to rethink how you're doing things.
Running through these drills identifies like,
is there an issue with the blood bank,
do we have a problem with the paging system?
So you can bring things to light sometimes
that you otherwise might not have an opportunity to see.
And you know, I just can't emphasize enough,
you know, perfection's the enemy of the good.
Some days,
all you can bring yourself to do
is to get a cup of coffee and be like,
"Where are those hypertension medications?"
You know, "How do we do an MTP?"
Honestly, I consider those inside your drills,
you do not have to do a whole drill,
it's not all or nothing.
Literally, if you're sitting around being like,
let's sing a song, we don't do very much, right?
How do we quick page pedes,
how do we activate a shoulder dystocia?
All of those things, as far as I'm concerned,
if you ask a question, run through a scenario,
and you can then have a little conversation,
also known as a debrief, about it,
you click that off,
you've slide it under your nurse manager's pen,
and get yourself a prize.
Because these are just the way
that every day with these little things.
So don't,
we have to just move this mindset of it's like a giant thing
or you don't do it,
literally a 15 minute conversation about,
where do get the meds, the order to push them,
and to discuss the little debrief,
or what's funny or interesting about it,
that counts 100%.
I will add that, in your drill binders,
we have scavenger hunts.
Those are always good
if you just don't feel like doing a drill,
so you can just find stuff on the unit.
Not that anybody wouldn't know where anything is on a unit,
like the new scalp electrodes
that actually come out of the baby's heads.
Who knows where those are?
Oh, you have to ask Amelie.
So, those kinds of things.
And I feel like at night, that is a really big issue,
the the Easter egg hunt of, you know,
I need a banjo curet,
and then I have a new LDA
that has no idea what I'm talking about.
[Marge] Or where's the clock on the wall?
Where's the clock on the wall?
How do I mark time?
How do I get her this thingy babobber that she wants?
Did CSR put it in the right packaging?
Did it actually get back where we're supposed to go?
You know, all those things,
they're system errors or system processes that,
you know, somebody new didn't know,
or put it somewhere that nobody knows where it is.
That's a simulation too, that's a drill too.
[Marge] But mostly guys, if you need anything,
I will tell you, we have developed so much stuff,
so certainly if you feel the need to develop it yourself,
you are always welcome.
but you are welcome to just shoot me an email
if you need something,
because 9 times out of 10,
we have something that, if it's not exactly what you need,
it's super close.
And honestly, if you ask me and I don't have it,
it probably means that we do need it anyway,
and so we can help.
So I just wanna emphasize to please,
anything that is funny about implementation or these drills,
please let us know.
And thanks, Julie,
there is the reminder about the next AIM team webinar,
and we're just gonna go a little deeper than we have,
going into with the hypertension rollout,
which is substantially easier than the hemorrhage one.
Now, just email me if anybody has any questions,
you guys do it,
you know how to find Julie,
you know how to find Sam,
thankfully, Julie's doing an excellent job
keeping me in line,
but Sam does whack me down a little more,
'cause she's right across the hall.
But you know, let us know.
Oh, do I have a good recipe for blood?
I mean, the blood that I make makes a huge mess.
I got it online, it stains participants,
so (laughs) I don't know if I would use my recipe.
The first time I did it,
one of our nurses was the patient,
and like three days later she texted me, she was like,
"My perineum is still bright red."
(Wendy laughing)
Like, sorry!
So. (chuckles)
Okay, the first thing for all of it,
don't look down there!
(Amelie laughing)
Yes, exactly.
But now I just like put blood,
fake blood on a chucks, and like,
I just use the same fake bloody chucks every time,
I don't necessarily like soak the patient
in fake blood anymore.
Amelie, if you find another recipe,
you can always send it my way,
and then I can share with this group.
Okay.
I didn't know there was recipe for making blood,
that's interesting. (chuckles)
Yeah, and it's all like, edible ingredients actually.
I don't recommend eating it, but. (chuckles)
Well, thanks for having us.
I hope this was helpful.
Thank you guys, let us know if you need help you at all.
Thank you.
Yes, here to help,
you can always reach out.
Have a good day, guys.
Thank you, Julie.
-Yeah, thank you, Julie. -For setting us all up.
-Thank you. -Thank you.