Simulation promotes real-life efficiency, safety, and better outcomes.
In a busy emergency department (ED), there is hardly a worse time of day than 1900 hours (7 p.m.). By then, every bed is occupied with patients presenting with anything from toothache to multiple-injury trauma. It’s the nature of the beast, and you learn early in your nursing career not to complain when it’s quiet, especially that time of day. The story I am about to tell began for me during one of those calm times—so calm it was almost unnerving.
We had just sat down for that rare moment of peace when the call came in from “Fire,” from a location not far from our hospital. The message was short and abrupt: “We have twin preemies just delivered.” Estimated arrival time? Seven minutes.
The charge nurse immediately assigns two RNs to rooms designated for the incoming patients—one room for the mother, the other pediatric-ready and equipped with an Ohio table to warm the newborns, both boys. The radio communication specialist (RCS) contacts NICU, Pediatrics, and anyone else he can think of who needs to know. The patients arrive by EMS (emergency medical services) transport at 1918, about the same time that the reality of caring for three acutely ill patients begins setting in.
The EMS side of the story
The paramedic reports what he knows: The mother, age 39, is gravida 5, para or parity 3. Translated, she has been pregnant five times with three of the pregnancies lasting 20 weeks or more and another two ending in spontaneous abortion. Appearing to weigh more than 350 pounds, she has not had prenatal care. She had planned to have a natural home delivery in her relative’s condo assisted by an unidentified “midwife,” but early onset of labor changed those plans.
When the EMS crew arrived at the scene, they found her on the floor, trying to “skin to skin” Baby A, who was cyanotic and breathing inadequately. Taking the baby from the mother, the paramedic clamped the cord, suctioned him, and saw immediate improvement in respiratory effort and color.
The mother, disoriented and combative, refused to move from the place on the floor where she was wedged between the wall and a heavy couch, so the medic had to negotiate with her to allow him to deliver Baby B. Too late! Baby B was between her legs and not showing signs of respiration. Moving quickly, the fireman was able to gain control of the preemie. After suctioning its mouth and nasal passage to remove copious secretions, he clamped the cord and passed the infant to a waiting crew, which initiated CPR. The estimated time of birth for Twin A was 1850, for Twin B 1911.
The ED side of the story
When the babies and mother arrive at the emergency department, it is 1918 and the older twin is about one-half hour old. Game is now on to take care of two acutely distressed, “27-weeker” babies tiny enough to fit in your hand. Emergent care requires neonatal and preemie airway equipment, including laryngeal scopes and blades, endotracheal tubes (ETT), suction catheters, ventilator, beds, IV catheters, oxygen equipment, umbilical catheters, and ambu bags. Our ED is equipped to handle neonates and infants, but two at once? We do our ever-loving best. NICU brings its transport cart, and the neonatologist and NICU respiratory therapist respond. In addition to my nurse colleagues and me, the ED physician is present.
Baby A is in distress. His heart rate is 100-plus beats per minute. He is extremely cyanotic, and his rectal temperature is 91.1 degrees Fahrenheit. After the baby is administered 100 percent oxygen with a hood, he is quickly placed in a transport warmer and immediately admitted to NICU, where he is intubated with a size 2.5 ETT, smaller than a drinking straw. His oxygen saturation is in the 70 to 80 percent range. A chest X-ray reveals total “whiteout.” After administration of surfactant, he is quickly weaned from the ventilator and begins breathing on room air. He is also given IV fluids and antibiotics. He weighs 895 grams, or 1 pound 15 ounces.
Baby B, whose heart rate has dropped below 100 beats per minute, is more of a challenge. His temperature is 93 degrees Fahrenheit and oxygen saturation 70 percent. When he arrived at the hospital, the EMS crew was still performing CPR. This baby is quickly intubated. There are some problems with intubation equipment but they are also quickly remedied. Once intubated, his heart rate climbs above 100 beats per minute, and he, too, is transported to NICU, where he is given surfactant, antibiotics, and supportive care. His weight is 948 grams, or 2 pounds 4 ounces.
The initial diagnosis list for both babies is extensive: Preterm adequate for gestational age 28 weeks, respiratory distress, respiratory failure, and severe pneumonia. Home delivery was uncontrolled and unsterile. Need to rule out sepsis.
Our third patient during that chaotic period is the mom. Belligerent, she is striking staff members, spitting, and yelling profanities at everyone. She had refused to be transported by the EMS crew until after she “took care of a few things” and was infuriated because she could not locate her cellphone. At ED, she presents with significant vaginal bleeding. She is given oxygen, numerous labs are drawn, and two IVs are started—one to maintain blood pressure, the other to administer Pitocin. She is transferred to Labor and Delivery (L&D).
To recap, three critically ill patients present to a busy emergency department, one of them belligerent. Although we had equipment available, it was not preemie size, and there wasn’t enough for twins. That rare moment of peace I mentioned in the first paragraph? It was just that, a rare moment. The department was still full of other patients needing attention!
It is said that all’s well that ends well. It’s true that the babies were well cared-for and, after a lengthy stay in NICU, discharged. But the experience caused undue stress for members of the ED as well as the EMS crew. We all felt we must and could do better. Next time, we decided, we need to be better prepared! And that’s the rest of the story!
What went right? What could have been improved?
The hospital’s neonatologist also recognized the need for improvement and held a debriefing for all staff members and pre-hospital personnel involved in caring for these patients. The entire case was reviewed. Things that went well were acknowledged, and then the focus turned toward improving our performance, with three of us agreeing to chair the process: Catherine Jagelewski, MSN, RN, a NICU nurse; Steve Greubel, RRT, NPS, C-NPT, AE-C, a respiratory therapist; and me. We had no idea the project would take two years to complete.
To achieve our objective, we followed Six Sigma’s FOCUS-PDCA
continuous quality-improvement model. The letters of FOCUS stand for Find, Organize, Clarify, Understand, and Select. PDCA stands for Plan, Do, Study (Check), and Act. The latter, known as the Deming Cycle, was developed shortly after World War II by Edward W. Deming.
Our problem was obvious: Our busy emergency department lacked a plan for imminent births. We had expert staff but no mechanism for getting them quickly to the bedside of an ED patient. We had some equipment, but none of it was for preemies. Although we had many well-qualified physicians and nurses, there was more talking than listening. We lacked order and process. In short, we had a chaotic mess that needed to be changed, and we were ready to make those changes.
You can’t improve what you don’t know is wrong.
First, we organized a committee composed of key stakeholders: nurses from ED, L&D, and NICU; respiratory therapists from NICU; and physicians from ED, neonatology, and obstetrics. We also invited ad hoc members from lab, ultrasound, radiology, registration, and spiritual care. We listened and incorporated suggestions. To get a better view of our weaknesses, we constructed a cause-and-effect “fishbone” diagram
Our hospital is designated a Level II Trauma Center
, so the first thing we focused on was development of a rapid response team. Borrowing a concept from trauma care, we added a Channel Access Protocol (CAP) number to the hospital’s trauma-alert pagers so that the Baby Emergency Team (BET)—as we called it—would have its own number. For departments lacking a trauma pager, we purchased the devices and showed members of those departments how to use them.
Criteria developed by the BET team were incorporated into the hospital’s policies and procedures. Since there are usually at least two patients involved in an emergency delivery—the mother and the baby—process algorithms have two sides or arms, one for the mom and one for the infant. BET activation is geared to get expert staff to patient bedsides within three minutes of notification by ambulance or triage. Any nurse can activate the team, which is done via Internet radio by the emergency department’s radio communication specialist. In addition to alerting the baby emergency team, the page also provides the team with a brief text description of the situation. Registration is part of this process. If the name is unknown, the military alphabet is used as a name with a medical record number. This is important: No number, no interventions!
Who does what?
When responding to a page, each member has specific patient assignments to eliminate uncertainty and confusion, just as members of a highly trained pit crew in professional auto racing have specific assignments that promote efficiency and safety, avoid duplication of effort, and contribute significantly to winning.
L&D and NICU each send two nurses for BET activation. One L&D nurse runs down the steps to reach the bedside as quickly as possible. The other comes by elevator, together with additional transport equipment, which, of course, takes more time.
Two emergency-department nurses are assigned to two resuscitation rooms (assuming just one baby is involved), one to ensure all equipment is available and functioning, the other, serving as a scribe, to document the process and maximize workflow. One NICU nurse is positioned to the side of the baby, the respiratory therapist is at the baby’s head, and the neonatologist or ED physician is at the baby’s feet, a vantage point from which he or she, like an orchestra maestro, can visualize the entire effort and provide direction, including staying on beat.
The labor and delivery nurse and the OB physician are with the mother, as is the other NICU nurse. The L&D nurse is positioned on the patient’s right side, and the NICU nurse stands by for immediate access to the newborn. Here, too, one emergency-department nurse will circulate about the room to ensure all necessary resources are available, and another ED nurse will serve as scribe. As team members arrive in the patient’s room, they announce their names and units—clearly—to ensure familiarity.
Working quickly doesn’t mean working unsafely.
The above “pit crew” approach ensures that, when the baby is born, seasoned experts are immediately on hand and in position at the bedside. There will be no rushing of a mother in labor through hospital corridors that separate the ED from L&D, all the while hoping the baby won’t be born in the hospital lobby or in an elevator. If either the mother or baby—or both—are distressed, it could be disastrous.
In developing this Baby Emergency Team approach, Greubel, Jagelewski, and I met with numerous managers, talked with staff members, and “unlearned” knowledge that each participating department thought was best practice.
We taught emergency-department staff members the importance of working with NICU and L&D staff members at the patient’s bedside, of helping the latter do what they are trained to do. We taught NICU staff members the importance of functioning as a team with ED staff members. NICU people needed to become less cloistered and to communicate clearly to other team members what they were doing for the patient in a manner that everyone could hear and understand. We had to make sure that, when the mother arrived, the L&D nurses and OB physician were firmly planted where they were needed, right next to the patient. This meant a switch of roles. Nurses find it uncomfortable, sometimes, to walk into the domain of another nurse, so to speak, and “take over.”
Do we have what we need? Do we know where it is?
Resuscitative equipment was a necessity. First, we compiled inventories of necessary infant-related items in sizes ranging from preemie to term. We also made sure that all equipment needed for mother-related interventions was properly identified and updated. For babies, Jagelewski and Greubel assembled a BET bag with everything needed for delivery or, if circumstances dictated, resuscitation. The equipment is neatly arranged, readily identifiable, in a kangaroo bag that hangs, ready for use, on the Ohio infant bed. I arranged to have drugs available in the Pyxis supply station for the mom. We also have an ample OB kit for her needs.
What has been the outcome? The Baby Emergency Team project has been one of the most rewarding of my entire career. When EMS radios to the RCS that they are bringing a mother who has delivered in a taxicab, here is what happens: The RCS radio-pages the BET team. Within one minute after receiving the page, the various members report to their assigned locations near the patients—mother and child. BET members introduce themselves to the ED nurses, and ED staff members move the Ohio table, with kangaroo bag, into the patient’s room. A brief report of what is known is given to all BET responders (physicians, nurses, and respiratory therapists). The ED physician or primary nurse confirms that everyone is in his or her assigned position around the patient. Everything is calm; everything is ready. There is no rushing in and out of the room, no searching for equipment, no chaos, just calmness.
The patient(s) are presented to the team by EMS. Everyone else in the room is silent as they listen to the EMS report. As soon as the report is completed—fewer than 30 seconds—the team gets to work. We deliver the baby (or babies) and make sure the mother is OK. We stabilize all patients and transfer them to their respective units.
How did we get here?
How did we get to this high-functioning level? I designed in situ simulations for the entire ED clinical staff using interactive manikins, and Jagelewski and Greubel facilitated them. More than 10 variable-scenario drills were developed, and every registered nurse and ED team-care specialist is required to participate in this training. One scenario has the mom presenting in active labor with a severe impulse to “push.” Other times, we use the preemie twins’ case described above as a case study, duplicating it. Evaluators in the resuscitation rooms verify whether the assessment and interventions are appropriate. The simulation ends only when the patients are stable enough to transfer to their receiving units.
Each BET simulation is activated with pagers sounding and departments responding. It is as real as we can possibly make it. On one occasion, a neonatologist overheard an ED team care specialist make a comment that this was “nothing,” whereupon the neonatologist allowed the patient to “die.” It was a lesson for everyone. The point is well-taken: If you practice perfect, the real thing will be that way. After each simulation, I conduct a formal debriefing in which each step of the process is reviewed and critiqued. Based on these sessions, we tweak the process further, if necessary, to make it better. It is amazing how many things critical to success can be forgotten. I’m thankful that we discovered these shortcomings in simulation and not during a real event!
Since developing the Baby Emergency Team, we have had several “real” BETs, and they have gone incredibly well. We had a 15-year-old with abdominal pain present to the triage desk. A nurse placed her on a cart because she was so weak, did a quick look, and discovered she was delivering! She immediately called a BET, and the team was there in a couple of minutes. On that occasion, the ED was so packed with patients a resuscitation room was not vacant, so we moved a patient out of a small non-acute room to make it available to the new mom.
The last-minute change was made with no negative effect. Based on the pager’s text message, our team knew exactly what to do. The Ohio table with its kangaroo bag was placed in the hallway. The NICU nurse made it just in time to take the baby from the ED physician, who literally caught the baby as it was being delivered. The NICU nurse was immediately in full charge of the term baby, and both baby and mother did great. Our staff fully realized the need and importance of the BET system.
I am so proud of the work that Catherine Jagelewski, Steve Greubel, and I have done. The BET system meets a huge need. It is best practice to be prepared and organized.
Note: The above scenario is fictitious. However, it is important to state that this project did result from an event similar to the case study presented.
Mary K. McAdams, BSN, RN, CEN, CPEN, TNS, former manager of education at the Honor Society of Nursing, Sigma Theta Tau International, is currently clinical educator for Eskenazi Health's Emergency Department, ICU, and Burn Units in Indianapolis, Indiana, USA.