1. Foundations of Interprofessional Collaboration (FIPC): An Introduction to TeamSTEPPS® LEVEL 3 Focusing on Teamwork in the Clinical Environment Helping You Help Your Patients!

2. Introductions

3. Foundational Program Level 1 Level 2 Level 3
Learned about other health professions.
Built paper chain using TeamSTEPPS© concepts.
Level 2
Built transition of care plan as a team.
Practiced using the TeamSTEPPS© SBAR and CUS tools.
Level 3
Work as a team to provide patient care using the TeamSTEPPS© SBAR and Huddle tools.

4. Goal for Today…
Take the interprofessional and teamwork skills you learned over the last two years for a test drive!
To advance your interprofessional communication
and teamwork skills using TeamSTEPPS tools in
a high-stakes clinical environment to collaboratively
provide and optimize patient care as a part of an
acute care team.
The training will provide you the opportunity to take what you are learning on a test drive. It will provide the opportunity to apply, try and practice the skills you need when working on a healthcare team.

5. Today’s Schedule Overview of the Day Orientation to the Day
Patient Case
Debrief
Course Evaluation
During the FIPC Level 3 training your focus will be to practice team-based care for a patient with Anaphylaxis. We will begin by reviewing the identification, treatment and management of anaphylaxis. We will then review and practice team huddles and closed-loop communication. Following that we will transition into the simulation space where you will be oriented to the room and your patient. Following that the simulation will begin. The simulation will be run two times. Each simulation is followed by a debriefing where our primary focus will be on the interactions of the interprofessional team

6. Management of an Anaphylaxis Emergency in the Hospital

7. Anaphylaxis Definition
“A serious allergic reaction that is rapid in onset and may cause death.”
Anaphylaxis is a serious allergic reaction that is rapid in onset and can be fatal. Although it is relatively rare, it can occur anywhere to anyone so we all need to be ready. The good news is that it is usually treatable when it is diagnosed in time. Timely diagnosis can be tricky, though, as the time between exposure and death is usually less than 60 minutes. When patients die from anaphylaxis, it is usually because the treatment, epinephrine, wasn’t given soon enough.
National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network

8. Anaphylaxis Pathogenesis
EXPOSURE
IMMUNE REACTION
Anaphylaxis can be triggered by many types of antigens including foods (such as nuts, shellfish, dairy products, and eggs); medications (from prescription medications, such as antibiotics, as well as over-the-counter medications); venoms (such as from bites and stings); and latex. Adult anaphylaxis most commonly results from medication and venom triggers, whereas children are more likely to experience anaphylaxis due to food allergens.
The exposure leads to degranulation of mast cells throughout the body. The products released such as histamine and tryptase lead to symptoms including findings in the skin, such as…, the respiratory tract such as shortness of breath and wheezing, the cardiovascular system, including hypotension and the GI system in the form of N/V/d.
SYMPTOMS

9. DIAGNOSIS Acute onset of illness (minutes to hours) with:
The is a WIDE range of patient presentations with anaphylaxis. Most of the time, if you look for Skin/Mucosa findings AND either respiratory or cardiovascular findings, you’ll catch it. The catch is that 20% of the time, there are no skin symptoms and respiratory and CV symptoms are much less common. So, this is a very rare condition that we must always be on the look out for because it can lead to death in minutes. Our patient today with anaphylaxis will have the classic symptoms of skin/mucosa findings and either respiratory or CV symptoms.

10. Airway, Breathing, Circulation
EMERGENT
MANAGEMENT
URGENT
MANAGEMENT
Airway, Breathing, Circulation
Identify/Remove trigger
Fluid Bolus
Calm Patient and Consider Positioning
Identify patient with possible anaphylaxis
Bronchodilator
Steroids
Monitor, Oxygen, IV (bolus)
Antihistamine
Diagnosis (tryptase)
Epinephrine IM 0.3 mg
Continued stabilization and ongoing monitoring
STABILIZE
Once these emergent actions are taken, there are several other components to treatment that may be helpful for your patient. We want to emphasize, that although these may be helpful to the patient over the next few hours, they do not replace and shouldn’t delay the administration of epinephrine.
Fluid bolus – start or double check that fluid bolus has been started. 1 L isotonic fluid with a pressure bag.
Steroids take 4-6 hrs to work and may be helpful in preventing a second phase of anaphylaxsis hours later mg/kg methylprednisonlone) [Of note, There is no strong evidence that supports the use of steroids in the management of anaphylaxis}
Inhaled B agonist: Albuterol: 2.5 mg in 3 mL of saline and repeated as necessary
Antihistamines help treat symptoms, particularly urticaria. H1 antagonist (diphenhydramine) mg IM or slow IV. H2 antihistamines (cimetidine) 4 mg/kg IV.
It is important to identify the trigger in order to make sure the exposure is stopped…and also to prevent further exposure.
Given the unpredictable ways a patient can present with anaphylaxis, there is ofter uncertainty in diagnosis. Tryptase is one of the mediators released in anaphylaxis and will be elevated for 1-2 hours after the exposure. It takes ~2 weeks to get the result, so doesn’t help with management in the short term, but can be very helpful determining later if in fact the patient did have anaphylaxis and if there were therefore exposures that need to be identified.
With animations:
So, today, once you identify that your patient likely has anaphylaxis, the goal is to work as a team to stabilize the patient. Since each of the emergent actions needs to happen immediately, we suggest you take a moment to huddle and assign roles.
Once these emergent actions are taken, and the patient stabilizes, we suggest you call a second huddle to re-assess patient status and plan the next steps in the treatment.
Discharged with Long-term Management Plan and Education
Anaphylaxis Practice Parameter; Annals of Allergy Asthma & Immunology; 2015; 115:

11. Your Teamwork Toolbox…
Today you are going to have the opportunity to care for a patient with anaphylaxis. As we just discussed, there are several therapies that must be delivered very quickly in order to keep the patient safe. Before we start, we’d like to discuss a couple tools in your teamwork toolbox….

12. TeamSTEPPS® Key Principles
Team Structure
Identification of the components of a multi-team system that must work together effectively to ensure patient safety
Leadership
Ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources
Situation Monitoring
Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning
Mutual Support
Ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload
Communication
Structured process by which information is clearly and accurately exchanged among team members

13. Recipe for a High-Functioning Interprofessional Teamwork
Key the Ingredients of a huddle we will practice today are
Calling the huddle
Identify a leader
Input from all team members
Closed-loop communication

14. The Huddle
Huddles are quick team meetings to review patient information and decide on a plan of care approach.
A huddle helps the team be on the same page and adjust the plan based on changes.
The second is called a huddle.

15. When to Huddle At the beginning of a patient encounter.
During a patient encounter when…
Patient status changes
Team members change
Treatment is not working or additional needs
Particularly when cooridination between teammembers required. Eg, if there are many tasks by many people (particularly time sensitive/urgent tasks)

16. What should a Huddle include?
1. The problem
The plan
3. Who does what
4. Input/Agreement
Summarize patient status and identify critical issues.
- Actively seek information from each member of the team and speak up if you have knowledge that may be helpful to the patient or team
Modify the plan as needed.
Assign resources.
Elicit additional input and agreement from all team members.

17. How long and how often should we Huddle?
Your first huddle
After SBAR
NO more that 30 seconds
Your second huddle
After the epi and the patient is feeling better
1-2 minutes

18. Video of huddle before and during a patient event
Pre-Huddle
Inter-event Huddle
Key principles within the huddle (leadership, closed-loop, all voices, etc.)

19. Simulation Provides a “Safe Container” to Practice
Try something new…this is a safe environment to make mistakes.
Simulation can be a little unnerving and awkward.
Agree that what happens here, stays here.
SIMULATION
The goal today is really to get a chance to practice…go ahead and try something new. If it doesn’t go exactly as you’d like, that’s ok…our patients have reset buttons and we can just sit down and talk through it and probably learn a lot.
Something we want to warn you about is that simulation can be a little awkward….we’ve done our best to make this feel as realistic as possible and are hoping you’ll find that you can play along and learn a lot.
Finally, we want to ask that you maintain the confidentiality regarding what happens here so everyone can be comfortable being open during the activities.

20. Your Patient
Chuck Townsend 70 yo male admitted through ED with diagnosis of urosepsis
History of Present Illness:
C/O urinary pain, back pain and altered mental status
Neighbor dropped him off because he was in pain and confused
Patient only able to provide limited history in ED

21. Your Patient PMH Current Medications Labs Drawn in ED
COPD
Type 2 DM
HTN
Current Smoker (98 pack years)
Current Medications
Zosyn g IV Q 6 hours
Glyburide 10 mg PO BID
Metformin 850 mg PO BID
Amlodipine 10 mg PO Qday
Advair 50/500 1 puff BID
Albuterol MDI 2 puffs Q 4 hours PRN
Labs Drawn in ED
Significant were WBC 14, Lactate 2, Scr 1.1, Positive UA
Admitted to medicine floor for Urosepsis

22. Let’s get started… The Patient Primary Nurse Rapid Response Team
Physician
Pharmacist
Nurse
Additional Members may include Respiratory Care, Clinical Lab Science, or Health Policy Management

23. Tips for Today Use the alogorithim
Additional patient information is available in a chart in the room
General Roles
Leader (oversees, delegates, and leads)
Patient communication and assessment
Drawing up medications
Medication administration
Documentation (clipboard in the room)

24. Consider second line medications:
Phase 1:
The primary RN recognizes the patient has possible anaphylaxis, calls a Rapid Response, and communicates using SBAR.
Phase 2:
After the SBAR, the Rapid Response Team huddles around the patient to decide who is going to perform which of the following emergent actions.
Phase 3:
Once the patient stabilizes, team calls a second huddle in order to discuss next steps in patient assessment and management.
Identify an Event Lead
(Assigns roles and monitors situation)
Consider second line medications:
Methylprednisolone 1 mg/kg
H1 antihistamine: Diphenhydramine 25 mg IV
H2 antihistamines: Cimetidine 4 mg/kg IV
Assess & Communicate with Patient
(Physical exam, keep informed, obtain history, monitor vital signs & overall status)
Identify patient with possible anaphylaxis
Review Patient Chart for relevant History
(Other possible diagnoses? Possible causes of anaphylaxis?)
Identify & remove trigger
Once they’ve had an overview of anaphylaxis management and understand what/how to huddle (in whatever order you prefer), tie it together with this slide in which we walk through the ‘choreography’ of the case flow…
Explicitly state that the primary nurse will recognize diagnosis and incorporate into the SBAR to the team.
After SBAR, team will huddle at bedside to plan how to complete emergent tasks very quickly. ANYONE can call for a huddle.
Once in the huddle, they should agree on who will be the event lead (who will lead the huddles? – seems most realistic). We should provide coaching on what the event lead should do once selected.
Then, event/huddle lead will assign/affirm roles (affirming roles that other professionals self-select sometimes more effective). Be clear that there are six roles that need to be assigned during the first huddle. (Now that it seems clear they won’t actually be administering second line meds, I tried to pick six tangible roles for them to complete during the heart of the case. I think the challenge of our first list was that some of the emergent tasks weren’t meaningful (ABCs are ok if patient is talking). And we didn’t call out leader as a role).
Once role is assigned, the event lead should stand at foot of bed (not engaged in tasks) to ensure workload distribution, situation monitoring etc.
Once patient stabilizes, anyone on the team can call for the second huddle, to agree on and assign next steps.
Epinephrine 0.3 mg IM
Consider alternative diagnoses and additional testing
(consider confirmatory testing (tryptase))
Fluid Bolus
Start Oxygen and Bronchodilator
(Albuterol 2.5 mg in 3 mL of saline)
Anaphylaxis Practice Parameter; Annals of Allergy Asthma & Immunology; 2015; 115:

25. Let’s get started!