SCOUT Simulation Center OU Tulsa

SCOUT Simulation Center OU Tulsa Scheduling Request Template

Simulation Event Title: Author: Event contact info: Brief description of the curriculum: *Provide a copy of course syllabus New or Modified New Event Modified Event Modified Date: Event? Modified Curriculum Describe what modifications are being made to this event and what feedback or circumstances lead to this change.

DEMOGRAPHICS / LOGISTICS Requested Date/s Number of sessions Total Session length (hours per session) Number of Number of participants at each session Participants Total number Frequency of program Annual Bi-annual Quarterly (place an X) Monthly Weekly Other Learners Trainees Year of Study Class Size X all appropriate boxes Medical Students 1 2 3 4 Residents 1 2 3 4 5 Physician Assistant 1 2 3 Nursing Students 1 2 3 4 Social Workers 1 2 3 Allied Health 1 2 3 Other 1 2 3 4 5

Accredited for CME/CEU Professionals Total Yes No Provider Name and # Internal Medical-Fac./Staff Internal Nursing-Fac./Staff External Med Staff

External Nurse Staff

Other (explain) EMSA, Fire, Police, DHS

Departments Allied Health Pediatrics Place an X next to each department that will benefit Emergency Medicine Psychiatry from the training Family Medicine Surgery

Tandy Education Center - 4502 E. 41st Street, Room 1D08 - Tulsa, Oklahoma 74135 - 918-660-3448 Geriatrics Social Work Internal Medicine Physician Assistant Nursing Other (explain) Obstetrics/Gynecology

ASSESSMENT OF NEEDS Professional Practice New Procedure Gap identified by: Standard of Care External requirements (AAMC, ACGME, JCAHO, OSHA) National Patient Safety Goals Research Findings Other (please specify) This is a practice Knowledge Competence gap/educational need Performance Patient Outcomes of: (check all that apply) Prerequisite Describe the knowledge and skills that the learners should have prior to beginning course. Knowledge

DELIVERY AND IMPLEMENTATION OF EFFECTIVE EDUCATION Faculty / staff involved Name / Dept Role Email with training

Will there need to be faculty training or rehearsal prior to the first scheduled event? For example: Faculty expertise training on simulation equipment, A/V equipment, etc.

DEVELOPMENT OF GOALS AND OBJECTIVES Learning goals: Describe your learning goals for this event. These are broad and generalized and usually related to overall department, program, or unit goals

Learning objectives: Describe in terms what you expect learners to be able to know, do, or demonstrate upon training completion. Objectives connect the identified gap/need with the desired result.

ACGME Core In this section, please X which competencies the objectives will address. competencies: Medical Knowledge Patient Care Practice-Based Learning and Improvement Interpersonal and Communications Skills Professionalism System-based practice Other: SELECTION / CREATION OF INSTRUCTIONAL METHODS Content List the topics and describe the content to be covered by the curriculum. Presentation outline: (if applicable) Procedure steps: (if applicable) Each step of the procedure process you are teaching should be listed here. If you are following the procedure steps from Procedures Consult, ACS skills modules, or Lippincott Nursing On-line – please indicate the name of the procedure module you are using.

Assigned Readings or Videos: (if applicable)

References: If using Procedures Consult, ACS skills modules, or Lippincott Nursing On-line, the references for those modules will be used, however please feel free to add to their list.

Educational Strategies Please X the types of teaching methods you intend to use. and Instructional Readings Demonstration Whole-body manikin – assisted Materials instruction Presentation Simulation (SP) Team training (Classroom Role-play) Lecture Computer-assisted Debriefing instruction Group discussion Video Other Case-based Partial task simulator – teaching assisted instruction ASSESSMENT OF LEARNERS Assessment Strategies Place an X next to the assessment method(s) you plan to use to determine the knowledge and skills the learners have gained from the curriculum program. Learner-generated Video Learner-generated Video (objective, checklist) Learner-generated Video (objective, OSCE)

Direct observation (subjective) Direct observation (objective) Direct observation (objective, checklist) Direct observation (objective, OSCE)

Lerner Survey  Pre  Post Written Exam  Pre  Post Documentation  Pre  Post Standardized Patient Evaluation Self Evaluation Video Review Other (Explain)

ASSESSMENT OF EDUCATION PROGRAM Assessment of quality Describe the data collection method you plan to use to determine the participants’ reaction to the of the program and program, with particular emphasis on perceived satisfaction or usefulness of the training program. Include how you will collect feedback on the quality of the faculty’s instruction (e.g. interviews, focus the instruction groups, surveys, questionnaires). RESOURCE AND EQUIPMENT NEEDS Support Describe the departmental, hospital and/or external support and resources you have for the program. i.e. what equipment and/or supplies will you be bringing to the simulation center?

Sim Center resources List facility resources you will need. For example: personnel, Video Capture (LearningSpace), A/V, teleconferencing, kitchen use, etc.

Supplies / Props List any supplies / props you will need to have provided by the Simulation Center – include quantities, sizes, and types. Please describe as accurately as possible.

Rooms Exam Room (1-8) Conference Room (X all needed, or type in # for Debrief Room Skills Lab multiple of one type) Hospital Room/ER/ICU Computer Lab

Simulators Please X all simulation equipment you would like to reserve. Type # needed in the box.

Whole-body High Fidelity Manikins SimMan Essential Noelle Birthing manikin

Pediatrics Training Neonatal Resuscitation Baby Anne Pediatric IV arm Infant Intubation Head

OB-GYN Training

Airway Management Intubation Head, Adult Intubation Head, Infant Intubation Head, Neonatal (Baby Anne)

Emergency Care Procedures Central Venous Access Head, Neck, Ultrasound Central Venous Access, Femoral, Ultrasound

Other Procedures Advanced Catheterization trainer (female) Advanced Catheterization trainer (male) Arterial Puncture Wrist Biopsy Suturing Skin pad or knot tying board Code Cart with Defibrillator and rhythm simulator IV Arm Lumbar Puncture & Epidural trainer Port and PICC Line Access Manikin Knee Injection/Aspiration model

Other Simulators Not Listed Office Use Only Schedule Date approved: ______Date______Event approved: ______Date______