Scenario #1: Haiti Earthquake, Mrs. Flore Paui
Learner Group: 2nd year PT/OT students – need not have not been to clinic yet
Environment: Acute care hospital room
Authors: Karen Panzarella, PT, Ph.D., Nicki Silberman, PT, DPT
- Safely organize hospital room, including lines/monitors and furniture for safe patient mobility
- Identify and communicate discharge disposition to team members including patient, family, case manager
- Determine if patient can safely participate in rehabilitation session and why she is reluctant to participate
|C/T/B||Main Focus||CAPTE Criteria||Performance Measures|
|1||B||G||2.2.2. 22.214.171.124 cc-5.11||Maintains professional behavior in verbal and nonverbal communication in all interactions|
|2||B||G||cc-5.17||Introduces self to patient, family, team members|
|3||T/B||G||P-10||Sanitizes hands prior to patient contact|
|4||C/T||G||Confirms patient identity by verbalizing name and checking wrist band|
|5||C/T||3||Checks patient chart for Rehab orders (OOB, PT, OT, WB Status)|
|6||C/T||3||Cc 5.30||Conducts screening examination to ensure patient clear for participation in OT/PT (VS, ROM, Pain, skin inspection)|
|7||T||1||Safely removes CPM (if available)|
|8||T||1||126.96.36.199.28||Moves all lines to 1 side of the bed for safe patient transfer|
|9||T||1||188.8.131.52.8 184.108.40.206.7||Sets up wheelchair and ensures locks on both chair and bed prior to transfer|
|10||C||2||220.127.116.11||Identifies patient not safe/ready for discharge to home, especially to travel back to Haiti|
|11||C/B||2||18.104.22.168||Responds appropriately to questions regarding discharge disposition to both family and team members|
|12||C/B||3||Recognizes the lack of patient participation in rehab may be culturally based|
Synopsis of Scenario
- Patient is a 75 year old female 4 days status post Right total knee replacement due to a crushing injury from an earth quake in Haiti, patient was transferred to a US hospital for surgery
- Patient has been medically cleared for discharge from the hospital
- OT informs PT that the patient is stable and should be able to discharge to home, OT performed ADLs at bedside.
- Initial PT evaluation was done 2 days ago, but limited by patient complaints of pain
- The patient has been OOB a few feet in the room with a walker just to the chair
- PT enters the room for a follow-up treatment session as OT is completing treatment/ADL session
- Patient is received supine in bed with Foley catheter, IV and PCA pump in place. CPM on Right lower extremity (or knee wrapped with ace bandage and underlying dressing)
- Patient unable to make progress in transfers and ambulation status due to c/o pain
- Patient believes she should rest in bed and not do anything that causes pain to herself
- Screening assessment skills (VS, pain, ROM)
- Transfer training
- Gait training
- Team communication skills
- Knowledge of discharge disposition options
- Lines (Foley, IV, PCA) not set up on same side of bed
- CPM in place(if available) or knee wrapped, room NOT set up for safe transfer
- Daughter asks when mother will be able to return home to Haiti, she wishes to bring her home very soon
- SW asks to confirm discharge plan to home. OT states patient is ready for discharge
- Patient complains of too much pain to walk and believing rest is necessary over mobilization
Learners Roles & Staging
|1||PT||A few minutes into the scenario goes into patient room with walker, OT is currently in the room||See FACILITATOR REPORT TO LEARNER|
|2||OT||Is in the room at the start of scenario and has completed an ADL treatment session with patient (ROM of UE)||has completed an ADL treatment session with patient becomes a team member when PT enters the room|
Confederate Roles & Scripting
|Role||Tone||Timing of participation||Lines / Comments|
|Daughter||Concerned, anxious, somewhat cooperative||
At bedside at start of scenario
When PT suggests it may not be today
When told she needs to be up and walking around before she goes home...:
"I am all set for my mom to go back to Haiti in the next few days"
"I was prepared for today. I will take care of her, she has a bed in my home, etc..."
"No, I can care for her in bed until her pain goes away"
|SW||Pleasant, but insistent about getting patient discharged tomorrow.||Enters room after PT enters, PT and OT are confronted||
"Oh great, I'm glad you're here. I just want to confirm the discharge plan to return home for Mrs. Paui.
Do you think she'll be able to receive rehab in Haiti? She's medically cleared, so we need to get her out tomorrow." Leaves abruptly...
Facilitator Report to Primary Learner to Start Scenario
Separately: to the OT: this is the third OT treatment session with Mrs. Paui, s/p TKR. you are covering for the OT who has worked with her the past 2 days, you will be responsible to determine if Mrs.Paui is ready to be discharged back to Haiti and that her UE ROM is WFL.
To the PT: Mrs. Paui in 516 had a total knee replacement, and was cleared for discharge back to Haiti. I did the eval 2 days ago and tried to see her yesterday, but she's been complaining of a lot of pain and would not cooperate to get out of bed or ambulate. Here's her chart, I think OT is in there now doing ADLs with her, you two figure out her discharge, I've got to run up to med-surg; thanks for covering."
Technician Staging Directions
|Staged for Learners||Available for Learners to Use|
|Manikin||75 year old|
|Position||Supine in bed with CPM running on R LE or Right knee ace wrapped with incision with steri-strips, bruising around knee.|
|Moulage||ID band, Foley catheter to left side of the bed|
In-patient hospital room
Daughter seated at bedside
Bedside table with glasses, book, incentive spirometer, water
CPM on R LE (if available)
|Disposable Supplies||Extra hospital gown|
|IV||Saline right arm with pole on right side of bed|
|Medications||PCA analgesia in place on left side of the bed|
On chart results
CBC – WNL
PT/INR – WNL
Type and screen
Orders Page – PT, OOB, WBAT R LE, OT ADLs for return home
OT and PT initial evaluation
Progression of Events
|Time||Manikin Actions||Performance Measures||Cues/Confederates|
Tone: anxious, cooperative, but having pain and not wanting to participate in PT
Script: "I can't get out of bed. My knee is killing me. I don't think I can walk today. I know they want me to go back to Haiti, but I just don't think I'm ready. Rest is what I need until this pain goes away." I will move my arms only"
Script: "I need help getting up. My knee hurts me. I don't think I can walk today" 9. Sets up wheelchair or bedside chair, and ensures locks on both chair and bed prior to transfer
|1||PT does not recognize patient not stable for discharge home||Daughter starts commenting that she doesn't think her mom will be safe alone at home and asking PT for advice|
|2||PT/OT not concerned about DC||SW insists on a discharge plan|
Integrated Debriefing Guide
|Threads||Performance Measures/Discussion Points||Debriefing Prompt|
Someone give us a quick summary of what was going on with this patient.
What went well?
What didn't go so well?
|Understand clinical presentation||
Conducts patient interview/history
Conducts screening examination to ensure patient clear for participation in PT (VS, ROM, Pain, skin inspection
|What signs and symptoms could we expect for this type of patient (s/p TKR)?|
|Identify contributing factors||PT/OT identify that culture may be playing a role in patient compliance to rehabilitation||
Describe some contributing risk factors we should consider....
How does this patient's culture affect this encounter?
|Recognize a change in patient status*||PT identifies patient not safe for discharge to home||
Looks/sounds like things are changing – what is concerning at this point?
How do we involve the daughter and patient in the plan?
|Identify correct intervention / treatment||Checks patient chart for PT orders (OOB, PT, WB Status)||
What are some standards of care for this type of patient?
What other options for care would be reasonable?
|Understand cultural implications||PT/OT determine that patients lack of participation is not just pain related after checking on medication administration||
What thoughts do we have about how this patient's beliefs may impact outcomes?
How do we best address their beliefs?
|Assessment*||Conducts screening examination to ensure patient clear for participation in PT (VS, ROM, Pain, skin inspection||
Thoughts about types of specific assessments that are important for this patient...
What are priorities for this patient?
|Infection Control||Sanitizes hands prior to patient contact||What infection control practices would we need to consider?|
|Medication Administration*||Identify the pain medication schedule and timing of the PT visit.||What medications could be considered? In what order should they be given? How?|
Moves all lines to 1 side of the bed for safe patient transfer
Sets up wheelchair and ensures locks on both chair and bed prior to transfer
|Talk about some concerns and options on how we could keep this patient safe...|
|Documentation||What information would we want to document? What are strategies for doing that during a crisis?|
Introduces self to patient, family, team members
PT responds appropriately to questions regarding discharge disposition to both family and team members
What additional information would we like to have had from PT 1 who has been involved in the this patients care?
As a newcomer to the patient situation, what information would be helpful? What information should be relayed from OT to PT? from team to SW?
Let's practice giving an SBAR about this patient......
What are some strategies for handling difficult family members?
PT identifies patient not safe for discharge to home
PT/ OT discuss possibilities for patient
Discuss some strategies to prevent us from becoming task focused....
What resources could be accessed for help?
|Decision Making Prioritization*||
PT/OT identifies patient not safe for discharge to home
PT/OT responds appropriately to questions regarding discharge disposition to both family and team members
|How were decisions made?|
|Leadership*||PT responds appropriately to questions regarding discharge disposition to both family and team members||How were roles delegated? How was leadership established? What actions did the leader take to ensure situational awareness?|
|Professional Behavior*||Maintains professional behavior in verbal and nonverbal communication in all interactions||
How were we coming across?
What are some strategies for managing difficult interactions?
How well do we understand the roles of all OT, PT and SW?
What would we do differently next time?
Does anyone have any additional questions or comments?
* = typical event to stop/review with video replay