Simulations for Teaching Students How to Transfer Medically Fragile Patients

“Simulations for Teaching Students How to Transfer Medically Fragile Patients”

Final Report

6/30/2011

Ketki D. Raina, PhD, OTR/L 412-383-6614; [email protected] Joanne Baird, MA, OTR/L 412-383-9891; [email protected] SHRS, Department of Occupational Therapy 5012 Forbes Tower Pittsburgh, PA 15260

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 1 FINAL REPORT

Project Goals: The goals of this project were to: (1) develop clinical scenarios to be used as exemplars for teaching (2) determine the clinical utility and cost/benefit ratio of using contextually-appropriate medical simulations to teach occupational therapy students how to transfer (move patients from one surface to another) medically fragile and clinically complex patients in an acute care hospital environment.

Evaluation: (1) Evaluation of clinical utility consisted of: comparing the skill competency scores from Phase III WISER center transfer scenarios for each teaching method using a one-way analysis of variance (ANOVA), with an alpha of p < .05. (2) Evaluation of cost/benefit ratio consisted of dividing costs of each method by the student outcomes for each method.

======Project Design: Students were randomly allocated to one of three Methods: Method A (1 active participation, 2 active observation), Method B (2 active participation, 1 active observation), and Method C (3 active participation, 0 active observation) (Figure 1). In the first phase, Skill Development, all students received the traditional classroom instruction comprised of lectures of body mechanics for the patient and the therapist, and laboratory sessions in which students practice transferring their able-bodied classmates. Skill in transferring patients was determined with written and practical examinations. All students had to demonstrate competency at this phase to be able to participate in the next phase. In the second phase, Skill-in-Context, students were randomly allocated to Method A, B, or C. This Phase consisted of advanced transfer skill training in contextually accurate settings, using simulators to mimic patients typically encountered in hospital settings. Finally, in the third Skill Competency Phase, students were randomly assigned to 2 of 4 clinical scenarios to determine competency in transfer skills.

Figure 1. Study Design

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 2 Project Goals:

1. Development of Clinical Scenarios

We developed seven clinical scenarios that were reflective of patients generally seen by occupational therapists in hospital settings (Table 1). Each scenario contained a brief medical history, the specific intervention required by the student, and objective competencies necessary for successful completion. Scenarios were designed for a simulator, that provided dynamic feedback in response to students’ actions, and extensive use of the medical equipment commonly found in hospital settings (e.g., vital signs monitors, IV lines, surgical drains). Each scenario consisted of 14 procedural competencies that were common among all scenarios (e.g., Proper infection control procedures are followed, wheelchair breaks are locked and wheelchair stability is checked prior to beginning transfer) and 4 critical competences which were unique to each scenario (e.g., no water is allowed to enter the airway through the tracheostomy, elevation of bed is stopped until vitals become stable again). Competencies for each scenario are rated as 1 (Yes) or 0 (No). Scores for the 18 competencies were summed to give a final score and then converted into percentages (Table 2). The medical scenarios and assessment competencies were circulated among 5 faculty and 3 doctoral students in the Department of Occupational Therapy for review and feedback. The reviewers rated each scenario for ecological validity, degree to which each scenario assesses patient and therapist safety, degree to which each scenario assesses equipment and technology management use, and the overall complexity of each scenario on a 10-point scale with 1 being the lowest and 10 being the highest. Based on the ratings and feedback, changes were made to the medical scenarios and assessment competencies. Based on ratings of overall complexity, scenarios with equal complexity were divided to be used in Phase II or Phase III of the project (Table 1).

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 3 Table 1: Scenario Description

Scenario Students were Critical Event required to: Phase II Surgical Drain Secure a Jackson- Maintain a gravity assisted drainage placement Management Pratt drain prior to without pulling on tubing by unclipping and transfer reclipping drain. Cardiac Symptom Alert medical Recognize drop in vital signs, alert personnel via Management personnel of call button at bedside, and explain the situation bradycardic episode calmly. during the transfer Nasal Oxygen Transfer wall oxygen Accurately and safely transfer oxygen without Management to portable oxygen disruption longer than 60 seconds. tank prior to the transfer Phase III IV Management Manipulate Unplug IV pole from congested wall outlet antecubital IV line cluster, keep tubing from pulling, prevent IV from and pole prior to, dislodging at site. during, and after the transfer Urinary Catheter Manipulate catheter Maintain a gravity assisted drainage placement Management tubing and bag prior without allowing the tubing to twist or become to, during, and after taut, safely secure catheter bag to wheelchair, the transfer allowing patient dignity. Orthostatic Respond to postural Head of patient is elevated slowly with vital signs Hypotension hypotension observed until the full upright position is Management achieved. Elevation of bed is stopped until vital signs become stable again. Tracheostomy Maintain Maintain an intact humidified oxygenated airway Management tracheostomy patency without allowing water to enter through with a humidified tracheostomy. airway

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 4 Table 2: Sample Competency Rating Form (Cardiac Symptom Management).

Yes No ASSESSMENT CRITERIA: Proper infection control procedures are followed (hands are washed).* Vital signs are recorded at start of session. * W/C is positioned as close to the bed as possible. * W/C brakes are locked and w/c stability is checked prior to beginning transfer. * Leg rests and arm rests are removed or swung out of the way. * Clear directions regarding patient's role in transfer are given. * Patient is moved supine to sit safely (via elevation of the head of the bed, or safe manual handling techniques). * Patient is scooted to edge of bed with buttocks remaining on mattress. * Bed height is adjusted to allow the patient’s feet to touch the floor. * Upright posture of the patient is supported by using proper hand placement that prevents a loss of balance on the edge of the bed. * Movement from bedw/c is done in a smooth and controlled manner, with no jarring or sudden movements. * Proper body mechanics are used during transfer (back straight, knees bent, head erect). * Notes that vital signs are not stabilizing. † Nurse is called. † The change in patient condition is calmly and accurately reported over the call system. † The patient is reassured that the nurse is being called. † Leg rests and arm rests are replaced. * Vital signs are recorded at end of session. * Final Score (total possible=18)

Note. * = Procedural competencies common among all scenarios. † = Critical competencies unique to each scenario.

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 5 2. Evaluation of Clinical Utility: We conducted the following statistical analyses to evaluate the clinical utility of each of the teaching methods: (a) We compared the competency scores obtained from Phase III for the three Methods using One-way Analysis of Variance (ANOVA). (b) To determine if the minimally clinically important difference was achieved we categorized scores for each Method into students who achieved the minimal competency requirement (Competency Composite Score ≤ 80%) and those who did not. The proportions of students in each Method who did and did not meet competency were compared using Chi-square test.

Results: One way ANOVA revealed no differences between methods for total competency scores (Table 3). Chi-square analyses revealed no differences between the methods for the proportion of students who passed and failed the competencies (Table 4).

Table 3: Descriptive data (%) and ANOVA results for percentage of competencies achieved

Method A Method B Method C F n M (SD) n M (SD) n M (SD) --- 34 83.2 (9.5) 37 83.8 (7.0) 34 84.8 (7.3) 0.361 * p < 0.05

Table 4: Descriptive data (%) and χ2 analyses results for proportion of students who passed and failed the competencies in Phase III.

Method A Method B Method C χ2 n % n % n % --- Pass 22 65 27 73 27 79 1.849 Fail 12 35 10 27 7 21 * p < 0.05

3. Evaluation of Cost/benefit Ratio: To evaluate the cost/benefit ratio, we divided the total cost for each method (WISER expenses + expert rater expense) by the proportion of students who had passed 80% of the competencies. The cost/benefit ratio was 14.74, 40.92, and 72.48 for Methods A, B, and C respectively indicating that Method A delivered the most benefit for the lowest cost.

Table 5: Cost, pass proportion, and cost/benefit ratio for Methods A, B, and C.

Cost ($) Pass WISER Proportion Ratio Expert Rater Center (%) Method A 360 156 65 14.74 Method B 780 325 73 40.92 Method C 1080 442 79 72.48

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 6 D. Conclusions

The 7 clinical scenarios were effective for teaching students how to transfer medically fragile and clinically complex patients in an acute care setting. Of the 3 methods employed to teach students how to transfer patients, Method A (1 active participation, 2 active observations) seems to have the most clinical utility and cost/benefit ratio.

Based on the findings from this study, we have integrated simulation-based training in OT 2113 Rehabilitation Theory and Practice as a regular learning activity. For training purposes, students will visit the WISER in groups of 3 and experience three scenarios (surgical drain management, cardiac symptom management, nasal oxygen management). All transfers will be videotaped and students will be provided detailed feedback regarding their performance. For competency assessment, students will be randomly assigned 1 of 4 scenarios (IV management, urinary catheter management, orthostatic hypotension management, and tracheostomy management) and they will have to transfer the simulators. All transfers will be videotaped and students will be provided detailed feedback regarding their performance.

A manuscript is currently under preparation to report study findings. The manuscript will be submitted to the journal Medical Education by the end of the summer. We will also present findings from the study at the American Occupational Therapy National Association Conference next April. In addition to competency data, we also collected data on student self-efficacy at the end of each phase. These data are currently being analyzed as part of Joanne Baird’s dissertation. Findings from the self-efficacy data will also be submitted for publication.

We would like to thank you for this invaluable opportunity to work on this project.

Simulations for Teaching Students How to Transfer Medically Fragile Patients Ketki D. Raina, PhD, OTR/L and Joanne Baird, MA, OTR/L Page 7