1. 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

2. 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

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

4. Stroke thrombolysis

5. Stroke thrombolysis

6. MAJOR HAEMORRHAGE

8. MAJOR HAEMORRHAGE

10. Sepsis 6 delivery before in-situ simulation

11. Compliance with sepsis six bundle

12. Delirium Management within ED

13. 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

14. 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

15. 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

16. 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

17. 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

21. 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

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

23. 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)

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

27. 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

28. Identification
4AT

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

30. One Minute Wonder

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

38. Demonstration

39. Results

42. What next
Can we keep it up
Think about frailty
Spread

43. The culture must be right

44. Any questions?