Day in the (hospital) life: Saving Noelle, a ‘high-fidelity tetherless human patient’
By kbleizeffer Feb 11, 2015
WATCH: Ben Wilson and Alex Salvador, simulation specialists at Swedish Medical Center in Seattle, Wash., introduce Noelle, a high-fidelity tetherless human patient birthing simulator.
In a hospital, a life-and-death emergency takes a team of experts: From nurses to doctors, from anesthesiologists to communication operators. Every person has a job. But after the emergency, it can be hard to take a big-picture look at the system of care provided. That's why simulation and drills are so important.
Last week, Wyoming Medical Center dissected its entire system of care for one particular emergency - postpartum hemorrhaging, or excessive bleeding after childbirth. A team from Swedish Medical Center in Seattle, Wash., facilitated a three-day simulation, bringing along its high-fidelity tetherless human patient birthing simulator named Noelle. (Watch the above video to see all that Noelle can do.)
“We use facilitated macro simulation to bring together big teams of people, who work together on a daily basis but don’t ever get to sit and talk with each other,” said Theresa Demeter, director of simulation services for InSytu Advanced Healthcare Simulation at Swedish Medical. “We are bringing together OB providers, anesthesiologists, nursing staff, unit secretaries, the blood bank, laboratory staff – all to look at this one event together.”
Swedish facilitated nine different simulations, running 8 to 10 medical professionals through each two-hour drill. In this post, we will walk you through one of the sessions, beginning on our Mother and Baby unit shortly after Noelle has given birth to a healthy baby.
Noelle is high-fidelity tetherless human patient birthing simulator. She breathes, blinks, talks and can even give birth to a baby manikin. In this scenario, Noelle continues to bleed after a successful birth.
Postpartum hemorrhage occurs in about 5 percent of births nationally each year. Last year at Wyoming Medical Center, 58 women experienced postpartum hemorrhaging out of just over 1,200 births. That's just under 5 percent of births. Of those, bleeding was controlled by medication, abdominal massage or minimal intervention in 54 cases. Four patients required more aggressive treatments in our operating room, similar to the treatments practiced in this simulation.
“Giving our clinicians the opportunity to practice these scenarios better prepares them for when the real emergency hits,” said Rhonda Franzen, risk manager at Wyoming Medical Center.
This simulation was a collaboration between Wyoming Medical Center; Swedish’s Gossman InSytu Advanced Healthcare Simulation team ; a consulting team from HPI, Healthcare Performance Improvement; and Western Litigation, a risk management company.
The simulation examined systems of supply, equipment, protocols, workflow, safety behaviors, the culture of safety and identified the barriers to the very best and safest patient care, Demeter said.
“We help identify some of the things that need to be fixed and the best team within the hospital to fix them. We try to get 90 percent of ‘the everybody’ who would care for a postpartum hemorrhage patient to participate in the simulation,” she said.
At the start of the simulation, nurse Abby Redden, acting as Noelle’s primary nurse, responds to Noelle’s complaints of light headedness and not feeling well. Upon assessing the patient, Redden discovers that Noelle is bleeding more than she should after childbirth. Redden calls for assistance with the call light on the headboard.
Normal bleeding occurs after childbirth from open blood vessels in the uterus (which previously provided blood to the fetus) as the placenta begins to separate. The uterus typically contracts after placental separation, clamping down on the blood vessels. In a postpartum hemorrhage, that contraction doesn’t happen the way it should. Medical staff can give medications or massage the uterus to encourage contraction. If that doesn’t work, more aggressive treatments are needed.
More medical staff respond to Noelle’s bed. Nurse Sue Renz (center) helps assess the patient while nurse Donald Coulter uses the portable phone to notify the “patient’s” physician, who will give care orders to be completed until he arrives at the bedside. The nurse will also notify the blood bank, charge nurse and laboratory of the situation. In this drill, Coulter calls the hospital operator to announce a “Mock Rapid Response” over the hospital’s PA system, activating the Rapid Response team.
Dr. Brian Veauthier, an attending physician from University of Wyoming Family Medicine in Casper, is briefed on Noelle’s deteriorating condition. Primary nurse Abby Redden massages Noelle’s abdomen in an attempt to contract the uterus and slow the bleeding. Dr. Veauthier asks for the on-call OBGYN and that an available Operating Room and OR team be made ready.
Swedish Medical techs control Noelle through this tablet. Techs can control her vital signs - including heart rate and blood pressure, bleeding, eye movement and more through the computer. They can also make her speak, have a seizure or a heart attack.
A sign hangs on the door to the OR area of the Ruth R. Ellbogen Family, Mother and Baby Center notifying patients and visitors to the drill.
When the bleeding does not stop, Noelle is rushed to the operating room on the Mother and Baby unit. Nurse Sue Renz (at left) grabs her OR gear -- including a hair cap, face mask and gloves -- and follows the crew into the OR.
The team prepares Noelle for a D&C (dilation and curettage) and insertion of a Bakri Balloon. In a D&C, the physician scrapes the inside of the uterus to remove all products of conception, which may be causing the hemorrhaging in cases where the placenta does not completely detach. A Bakri Balloon is a silicone catheter used to put pressure on the uterine arteries and control bleeding.
Dr. Dale Reisner, a perinatologist at Swedish Medical, acts as the OBGYN for this simulation, called in to assist Dr. Brian Veauthier. She specializes in high-risk obstetrics and was part of the training team from Swedish who facilitated the simulation.
Jennifer Cockrum, nurse education coordinator in Mother and Baby, intubates Noelle so medical staff can control her breathing. The anesthesia administered puts the entire body to sleep, even the diaphragm.
Nurses secure Noelle’s legs in Yellofin Stirrups to prepare for the procedure. The nurses in pink are from our Mother and Baby unit. The nurse in blue is from the Operating Room staff.
Dr. Brian Veauthier practices inserting the Bakri Balloon with Dr. Reisner’s help.
After the simulation has ended, the medical staff debriefs about what just happened. A big part of this simulation process is identifying ways to streamline care and make it more efficient. The entire simulation was filmed and the team later watched the footage together to identify what went right and what needs work.
From all the simulations, Swedish Medical will make a list of recommendations for Wyoming Medical Center to consider implementing in its processes. It collected hospital data related to postpartum hemorrhage – such as number of transfusions, patients admitted to ICU and unplanned hysterectomies – for 12 months prior to simulation and will collect the same data 12 months after. This will show the benefits of the improvements in care resulting from the simulation, Detemer said.
Swedish staff presented an hour-long outbrief to hospital leadership identifying issues with supply and equipment, protocols, staffing and more. They’ll also identify all the things the team did well. Wyoming Medical Center will use the recommendations to improve care.
In all, a total of nine teams went through this simulation over three days. Two different operating rooms were used – the new OR on the Ruth R. Ellbogen Family Mother and Baby Center, and an OR on the third floor of the Center Tower. In a real emergency, the Mother and Baby OR might not be available, and staff needs to know the quickest, most efficient way around both. Here, the team is finishing a simulation in OR 1.