In situ simulation training in the ED A combination of innovation and team learning leads to real quality improvement Julie Mardon Lead for Simulation Ayrshire and Arran and Consultant in ED

Objectives Describe the use of team training using in situ simulation training as a quality improvement tool within the ED Describe delirium management within ED and the challenges and barriers for change Illustrate methods used to improve patient journey including demonstration Share results Explore future developments

Simulation training in the ED Used regularly within Crosshouse Hospital for many different patient safety, research and training purposes

Stroke thrombolysis

Stroke thrombolysis

MAJOR HAEMORRHAGE

MAJOR HAEMORRHAGE

Sepsis 6 delivery before in-situ simulation

Compliance with sepsis six bundle

Delirium Management within ED

Increasing number of elderly patients presenting to ED Up to 30% of elderly presenting to ED have delirium Studies suggest that physicians correctly diagnose delirium in 25% of cases Failure to detect delirium in ED has potential for increased mortality up to 6 months after presentation

Elderly patients diagnosed with delirium in the ED have up to 26% mortality in 12months SAME AS ACUTE MI AND SEPSIS ED physicians should consider delirium as a medical emergency Early diagnosis and treatment improves long term outcomes

No sense of urgency ? Not in ED Why? Multiple demands on time Many other time critical conditions CVA MI sepsis major trauma paeds emergencies etc The box

Learning objectives Increased awareness of importance of early identification of delirium at the ED front door Practice assessment of patient and family presenting with delirium Pilot In situ simulation scenario designed

Pilot of in situ simulation Simulated patient Simulated relative Doctor and nurse from within department Other participants Multidisciplinary faculty experts from frailty team, ED, simulation elderly mental health and quality improvement

Assessment Multi-disciplinary team Excellent feedback Anecdotal change in practice Roll out to all staff I wanted to say that I found the teaching yesterday a very valuable experience and really took away some positive ideas to change my clinical practice. I was glad to have been picked to take part. I’ve started using the 4AT its really easy! I now understand the difference to patients using the 4AT can make

Next steps Formal assessment of data Involve other experts and interested parties Learn from other areas GRI Fife Lanarkshire What will we measure

AIM 80% of patients over 65 have 4AT completed No patients with positive 4AT (or presumed delirium from the notes) have missed delirium 6 months time (by April 2017)

Baseline data Symphony search all patients over 65 admitted via ED in Crosshouse hospital 10 patients per week (sept 2016)

Process mapping 4AT to print off for all over 65s Confidence in 4AT Mutual understanding of meaning of positive 4AT Communication with family and team Call it Delirium

Identification 4AT

TIME BUNDLE Used in ward settings Too cumbersome for ED Modified sticker with relevant information

One Minute Wonder

Delirium simulation 4 sessions run Identifying patients 4AT Practice discussion with team and relative

Demonstration

Results

What next Can we keep it up Think about frailty Spread

The culture must be right

Any questions?