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Handoff and Airway Management in Recovery 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Implementation of Standardized Post-anesthesia Care Handoff and Airway Management in Recovery Carrie Falasca and Haley Scroggham Marian University Leighton School of Nursing Chair: Dr. Lee Ranalli _________________________ Project Committee Members: Deborah Miller _________________________ Project Team Members: Haley Scroggham Haley Scroggham, SRNA Carrie Falasca Carrie Falasca, SRNA Date of Submission: April 29, 2024 Handoff and Airway Management in Recovery 2 Table of Contents Abstract .......................................................................................................................... 4 Introduction .............................................................................................................. 5 Background ................................................................................................................ 5 Problem Statement .................................................................................................. 7 Organizational Gap Analysis of Project Site ............................................................ 7 Review of the Literature ............................................................................................... 8 Theoretical Framework/Evidence-Based Practice Model/Conceptual Model..... 11 Goals/Objectives/Expected Outcomes ........................................................................ 11 Project Design/Methods .. 12 Project Site and Population ........................................................................................... 13 Measurement Instrument(s) ........................................................................................... 13 Data Collection Procedure ............................................................................................. 13 Ethical Considerations/Protection of Human Subjects ....... 14 Data Analysis and Results 15 Conclusion ................................................................................................................... 19 References ..................................................................................................................... 20 Appendix A . 23 Appendix B.............................................................................................................. 28 Appendix C.............................................................................................................. 29 Handoff and Airway Management in Recovery 3 Appendix D. 30 Appendix E.. 31 Appendix F.. 36 Handoff and Airway Management in Recovery 4 Abstract When a patient arrives at the postoperative anesthesia care unit (PACU), a transfer of care report from the anesthesia provider to the PACU nurse occurs at the bedside. Historically, there has been a lack of completeness in handoff reporting that has led to numerous avoidable medical errors. The goal of this quality improvement project at a 25-bed critical access hospital in rural Indiana was to implement a standardized handoff tool in the PACU. Secondly, an in-service was provided on airway management amongst special populations across the lifespan to improve the quality and safety of patient care in rural communities. A pre-test survey was used to evaluate the anesthesia department and perioperative nurses opinions of the current handoff process. A standardized handoff tool was then implemented along with an in-service on airway management of special populations. A post-intervention survey was used to determine if the post-anesthesia tool made handoff a more streamlined process. Unfortunately, due to the lack of participation from participants, results were inconclusive to determine if the standardized handoff tool improved the transition of care process in the recovery room. Keywords: perioperative, handoff, post-anesthesia care unit, communication, standardized tool, checklist, reporting tool. 5 Implementation of Standardized Post anesthesia Care Handoff & Airway Management in Recovery This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. The absence of proper communication during the transfer of care of patients from the surgical suite to the post-anesthesia care unit (PACU) has resulted in numerous medical errors resulting in morbidity and mortality. Despite this phenomenon, there is still an absence of formal handoff in many healthcare facilities when transferring care of patients. The purpose of this evidenced-based quality improvement project is to establish a standardized PACU handoff at a 25-bed critical access facility to ensure patient safety and continuity of care. A thorough handoff and educational in-service provided to recovery room Registered Nurses (RNs) on airway management for specialty populations including pediatrics and bariatrics will improve patient safety, and quality of care in the community in rural Indiana where access to care is limited. Background When a patient arrives at the postoperative anesthesia care unit (PACU), a transfer of care report from the anesthesia provider to the PACU nurse occurs at the bedside. This includes the patients medical history, procedure, intraoperative events, and postoperative plan. After the report is given, the PACU RN assumes care of the patient. Neglecting to give a thorough report is a violation of the American Association of Nurse Anesthetists (AANA) Standards of Practice Standard VII. Under this act, the anesthetist is required to accurately report the patients condition including all essential information and transfer the responsibility of care to another qualified health provider in a manner that assumes continuity of care and patient safety (AANA, 2016). Standardized Handoff Tool 6 Historically, hand-off reports on patients have been minimal and inconclusive leading to critical patient safety events leading to The Joint Commissions involvement. Under The Joint Commissions National Patient Safety Goals are the listed expectations for effective handoff reporting with a standardized tool (TJC, 2008). Without utilizing a checklist or tool to reference, providers are forced to recall pertinent details from memory that could be incorrect or missing information (Shah et al., 2019). Time restraints, interruptions, and multiple tasks taking place simultaneously are contributing factors to handover incompleteness. When there are too many distractions and a comprehensive report is excluded, serious patient safety events can occur such as airway emergencies, re-intubations, delayed discharges, and even death (Lambert, 2018). Different communication styles among providers are also a culprit in improper handoff. A standardized handoff fosters a systematic reporting style in which no intraoperative events must be recalled from memory. Disorganized inconclusive handoff is the cause of 80% of serious medical errors that occur perioperatively (Halladay et al., 2018). To avoid another statistic, standardizing the handoff process is best practice. In a critical access hospital in rural Indiana where access to care is limited, a provider needs to be well-versed in caring for patients across the lifespan. Safely recovering patients from anesthesia specifically, requires high vigilance and critical thinking skills. This critical access facility in rural Indiana has a high volume of bariatric and pediatric patients daily. There are many key airway differences between pediatric patients versus adults that anesthesia providers and recovery room nurses must be aware of. Transferring a pediatric patient from the operating room to the recovery room can be a very daunting time due to the fragility and reactivity of their airway. A Laryngospasm is a life- Standardized Handoff Tool 7 threatening airway emergency that involves the blockage of the airway that can quickly escalate to hypoxemia if not treated immediately (Furstein & Morey, 2023). To be able to recognize and immediately take action is a skill set required for a PACU nurse to have when recovering pediatric patients. It is also of the utmost importance to have the necessary emergency airway equipment readily available in the PACU bay. This includes a suction setup, a properly fitting Ambu bag, and quick access to an emergency airway cart or crash cart. The safety and efficacy of caring for patients in the special populations mentioned above start with proper handoff in the transition of care to PACU. A conclusive formalized process for handoff utilizing a checklist decreases perioperative miscommunication by increasing data transfer, and efficiency, and improves patient safety. Problem Statement Patients in the transition period between being anesthetized in the operating room suite, or procedure room to the PACU remain vulnerable. Inadequate or inconsistent handoff between the anesthesia providers and PACU RNs is a major patient safety risk when patients' lives depend on their competency. The goal of this quality improvement project is to implement a standardized handoff tool to improve patient safety, closing the gap between current practice and best practice in a 25-bed critical access hospital in rural Indiana. The second portion of the project is to provide airway management education to the recovery room RNs who see a high volume of pediatric and bariatric patients to improve the quality and safety of patient care. Needs Assessment and Gap Analysis The project site is a 25-bed critical access hospital in rural Indiana. Critical access facilities improve access to care by providing essential healthcare services in rural communities. Currently, there is no formal handoff process in the transition of care between the anesthesia Standardized Handoff Tool 8 providers and the PACU nurses. The goal of this DNP project focuses on developing a standardized and evidenced-based practice handoff tool to meet the requirements of the 2007 Joint Commission's National Patient Safety Goals (TJC, 2008). By utilizing the toolkit, Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS), education will be provided to PACU RNs on proper airway management while implementing a handoff tool into everyday practice. the study hoped to prove that the implementation of a standardized handoff process and specialty patient population education would enhance the satisfaction and confidence of those involved in patient transfer of care. Review of the Literature A review of literature was conducted in October 2022 to answer the following question: Does a standardized handoff tool used in the transfer of care to the PACU improve the quality, safety, and continuity of care for the patient as well as improve healthcare worker satisfaction in the process? Professional practice guidelines were obtained from the AANA, The Joint Commission, and the US Department of Defense Patient Safety Program (Dod PSP). The databases utilized for this review were PubMed, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) with the following search terms: anesthesia handoff, anesthesia transfer, standardized handoff, checklist, perioperative handoff, and PACU perceptions. 34 articles were identified and 10 were carefully selected after review, as shown in Appendix A. Inclusion criteria included transfer of care by anesthesia and articles that best answered the clinical questions. Exclusion criteria included articles published beyond the past 5 years and articles that did not contain evidence-based practice findings under the selected topic. A full literary matrix of all articles included in this literary review is included in Appendix B. Standardized Handoff Tool 9 Improved teamwork and employee satisfaction: When patient acuity increases, copious tasks with multiple distractions commence. Routinely utilizing the same checklist in handoff seamlessly guides the transition of care process allowing time to cross-check information amongst the healthcare team. A checklist also provides less room for error from missing information in turn less frustration from having to track people down for follow-up questions (Reine et al., 2020). However, for changes to be implemented, providers must be open and willing to accept change. Results of a study conducted by Lambert (2018), found that providers who are accustomed to taking written notes in reports are more inclined to implement a handoff tool into everyday practice and were observed to be the best change champions (Lambert, 2018). Consequently, the positive effects from using the tool provided for a familiar routine each time a handoff is given. A systematic review (n=27) and one quality improvement project (n= 135) reported increased employee satisfaction, after implementation of a handoff tool (Dalal et al., 2020; Lambert, 2018). 77 out of 79 anesthesia providers in a meta-analysis reported that it made the handoff process easier (Shah, 2019). Improved quality and continuity of care: 3 studies highlighted that there is an ongoing disagreement among providers on the essential components of handoff (Dalal et al., 2020; Gibney, 2017: Randmaa et al., 2017). However, after standardizing the handoff process, an improvement in the efficacy of handoff was seen along with a more comprehensive report (Dalal et al., 2020; Lambert 2018). Shahs study (2019), reiterated systematic handoff tools allow clear communication of concurrent information in which the receiver retains the information being reported. Patient Safety: Pertinent patient information left out in handoff is a direct link to poor patient outcomes. A checklist serves as a physical reminder to prevent information omission Standardized Handoff Tool 10 (Park et al., 2016). Each time the transition of care occurs from one provider to another there is the risk of human error from neglecting to inform the oncoming provider of pertinent patient data. A multicenter population-based study (n=102,156) found a significant increase in the number of post-operative 1-year mortality and well longer hospital lengths of stay when intraoperative anesthesia handoff was given (Sun et al., 2022). The strength of this study is that it reviewed patients over a decade with a large sample size. Secondly, one of the first randomized control trials on anesthesia handoffs compared patient outcomes of participants who received intraoperative handoff versus patients without with a sample size of 1,817 participants. The results of this study concluded that 52% of patients required ICU admissions postoperatively when intraoperative handoff of care was given (Meersch et al., 2022). Despite the limitations of this study having multiple variables that could have contributed to ICU admissions, it recapitulates the importance of proper handoff to prevent further complications. Communication failures associated with handoff may be one of the most important contributors to preventable adverse events in healthcare (Lowe & Geroge-Gay, 2017). After the implementation of a handoff in a pediatric hospital (n= 135) there was a significant decrease in the number of missing items that needed to be reported such as airway techniques, ventilation status, venous access, medications given, and pertinent intraoperative events compared to prehandoff tool results (P<0.001) (Dalal et al., 2020). Providing handoff in a systematic approach utilizing a checklist such as the SBAR, (Situation, Background, Assessment, Recommendation) information omissions are minimized in the handoff process (Reine et al., 2020). Several methods for standardized handoff from anesthesia to the PACU exist in the literature. Different tools and mnemonics were utilized in the handoff process reaching the same consensus that a standardized handoff tool is essential for patient safety and continuity of care. Standardized Handoff Tool 11 Theoretical Framework The John Hopkins Evidence-Based Practice (JHNEBP) model will be utilized to serve as a blueprint for the decision-making process of this quality improvement project. Inquiry is the starting point for this model. An individual or team seeks to identify if the current practice reflects the best evidence available (Dang et al., 2022). The JHNEBP includes a 19-step process that can be simplified into 3 phases. Practice questions, evidence, and transition or PET (Dang et al., 2022). The PET model provides a systematic approach to solving practice questions, finding the best evidence, and translating that information into practice. A visual representation of this process can be seen in Appendix C. This process is centered on the fact that healthcare is becoming increasingly complex and ongoing learning is necessary to remain current in best practice. The model encourages a spirit of inquiry and a culture of learning. Project Aims and Objectives The goal of this DNP project is to improve the handoff process between anesthesia and PACU RNs by implementing a standardized handoff tool. The primary purpose was to identify the barriers and reasons for incompleteness in the current handoff process. Secondly, we wish to improve the confidence level of PACU RNs when recovering bariatric and pediatric patients. We aim to implement a standardized handoff tool that complies with the Joint Commissions National Patient Safety Goal (TJC, 2008) while improving the staffs perception and satisfaction utilizing the tool in handoff. SWOT Analysis A thorough assessment was completed to identify the strengths and weaknesses of this project. The strengths of this study include using evidence-based practices to improve patient outcomes. Utilizing an evidenced-based practice handoff tool is accessible and easy to adopt into Standardized Handoff Tool 12 practice. The aim of this study target areas needed for improvement and gear the continuing education to improve patient care. The project encouraged staff to become more involved by recruiting a project champion. The project champion encouraged participation from co-workers. Utilizing a project champion has the potential to motivate future quality improvement projects at this clinical site. Examining and recognizing potential barriers involved in this project is as important as assessing the strengths. The key weaknesses of this study include a small sample size, the unwillingness of participants to adopt new changes, and data collection being dependent on participant engagement. A small sample size can skew results and lead to less reliable data. There is the potential for unwillingness of participants to adopt changes due to comfortability in the current process. The collection of data depends on voluntary participation, which can lead to a decreased number of completed surveys. A full SWOT analysis describing the strengths and weaknesses of this study is located in Appendix D. Designs and Methods This DNP project utilized a quality improvement design following John Hopkinss evidence-based practice (EBP) model. The TeamSTEPPS framework was used as a tool to successfully integrate efficient communication. The standardized handoff tool was created by Monroe Childrens Hospital at Vanderbilt University Medical Center. Permission for use was obtained from Laura Payne DNAP, CRNA, the Pediatric Anesthesia Service Specialist at Vanderbilt. This tool is compliant with the required data to be reported set forth by the Joint Commission (TJC, 2008). A digital presentation was created and sent to participants on airway management skills for bariatric and pediatric patients via PowerPoint. Permission to proceed Standardized Handoff Tool 13 with the project was obtained by the clinical lead at the facility and sent to the Institutional Review Board (IRB) at Marian University. All participation in this project was voluntary. Project Site and Population This project took place at a 25-bed critical access facility in the west-central region of rural Indiana. Currently, this facility offers a 24-hour emergency department, medical/surgical care, and three surgical suites. They specialize in orthopedic procedures, bariatric surgeries, pediatric ENT (ear, nose, and throat) surgeries, and pediatric dental services. The participants in this project include two Certified Registered Nurse Anesthetists (CRNA), one anesthesiologist, and ten registered nurses recruited voluntarily to be a part of this DNP project. Potential barriers include the reluctance to accept change from staff. Several staff members have worked there for many years together and may see that their current practice techniques work best. One champion nurse was recruited voluntarily to encourage staff participation and pilot implementation of the handoff tool. Measurement Instruments To evaluate the outcomes of this DNP project a pre-test/post-test design via Qualtrics (qualtrics.com) was conducted. The pre-test/post-test design examined the current opinions of the handoff process, knowledge base, and confidence levels of nurses recovering from bariatric and pediatric patients. A post-test was utilized after the implementation process to determine if the standardized handoff tool was effective in the participant's daily practice. Data Collection Procedures Pre-Intervention: The pre-test survey was sent to staff via email by investigators encouraging their participation. The pre-test survey contained 8 multiple-choice questions and 1 fill in the blank question. Our goal was to identify the perioperative staffs satisfaction with the Standardized Handoff Tool 14 current handoff process, the quality of information transfer, and what areas need improvement. This survey also identified gaps in management skills for pediatric and bariatric patients. Intervention strategies: After reviewing pre-test results, a PowerPoint presentation (Appendix E) was sent to participants followed by a live 1-hour voluntary in-service on how to utilize the handoff tool. The in-service provided education on how to incorporate the handoff tool, the benefits of using the tool, and outcomes based on personal experience with utilizing the tool in practice. A laminated copy of the handoff tool was then placed on the monitors of each PACU bay. This was first approved by the project site clinical coordinator and project committee member. Post Intervention: A post-test survey was utilized to examine if the education component has helped with the confidence in recovering pediatric and bariatric patients. Secondly, the survey questions asked if the handoff tool was easily adopted into practice and has helped the workflow. This survey consisted of 8 multiple-choice questions focused on satisfaction of current process, and knowledge assessment related to specialty populations. Ethical Considerations The Marian Internal Review Board (IRB) approval was obtained prior to initiating this project (Appendix F). No patients were involved in this study; thus no patient health information was included. Participants in this study were involved on a voluntary basis. It was disclosed to all participants that all responses in the pre/post-test surveys were anonymous. Due to the very small sample size, no demographic data was collected to protect the privacy of the participants. Participant confidentiality was protected by coding the participants using individual identification numbers. The aggregated data was kept in a locked secure location, only accessible by project team members. All electronic files containing identifiable information were kept Standardized Handoff Tool 15 password-protected to prevent access by unauthorized users. Only the project coordinators had access to these passwords. Data Analysis and Results Data from the pre-test and post-test surveys were analyzed with descriptive and inferential statistics to determine the effectiveness of the intervention. The data was analyzed using measures of frequency, central tendency, and variability. A total of nine registered nurses were eligible and participated in this project. Eligibility criteria included providers involved in the transfer of PACU patients at our project site. To determine satisfaction with the current transfer of care process and confidence with specialty patient populations the participants reported their satisfaction and confidence based on a 3-point Likert-like scale. Data from the pretest and post-test surveys were analyzed using paired t-tests to compare preintervention survey results versus postintervention survey results. Five questions related to satisfaction with the current handoff process and two questions focused on knowledge assessment. The results were analyzed in relation to their categories and as a whole. Satisfaction with the Current Process The first five survey questions assessed satisfaction with the current handoff process. These were based on a 3-point Likert-like scale. The results were analyzed with descriptive statistics to compare means pre-intervention versus post-intervention. Table 1 shows the mean results for satisfaction-based questions. A t-test with equal variance was then completed to determine the significance of the results. Table 2. Shows no statistical significance in satisfaction improvement (p=0.15) between pre-tests and post-tests. Standardized Handoff Tool 16 Knowledge Assessment The last two questions of the survey focused on knowledge assessment of airway management across the lifespan. The participants were asked to answer knowledge-focused questions based on a 4-point Likert scale. The results were analyzed with descriptive statistics to discover mean differences between pre-test and post-test scores. Table 3. Displays these findings. A t-test was then conducted to determine the significance of these results. These results showed no statistical significance in knowledge improvement pre-intervention versus post-intervention. This can be seen in Table 4. Although post-test scores slightly increased in knowledge-focused questions, the results were not significant (p=0.2). Standardized Handoff Tool 17 Table 4. Mean Variance Observations Pooled Variance Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail Pre-Test 2.352941176 0.992647059 17 Post-Test 2.545454545 0.672727273 11 0.869600987 0 26 0.53351013 0.29910614 Overall Results The overall results of the pre and post-tests were analyzed with descriptive and inferential statistics. Means were calculated for both pre and post-intervention surveys shown below. While overall scores increased slightly in the post-test, the results showed no statistical significance (p=0.4). In this case, there is little to no evidence to reject the null hypothesis at a standard significance level. This indicates that the observed results are likely due to random variability rather than a significant effect. Pre-Test Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Range Minimum Maximum Confidence Interval Upper Confidence interval Lower Confidence Level(95.0%) Post-Test 2.28125 0.112398 2 3 0.8991839 0.8085317 -0.1893662 3 1 4 2.5058595 2.0566405 0.2246095 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Range Minimum Maximum Confidence Interval Upper Confidence Interval Lower Confidence Level(95.0%) 2.3333333 0.116405 2 2 0.7543909 0.5691057 0.0662786 3 1 4 2.5684181 2.0982486 0.2350848 Standardized Handoff Tool 18 Discussion Overall, the participants score for knowledge-focused questions slightly increased (77%79%) after providing an educational in-service on airway management across the lifespan. When the questions are analyzed individually, they show no significant difference. When the surveys are analyzed as a whole the mean post-test score (77%) increased slightly from the pre-test score (76%), but again showed no statistical significance. When satisfaction-based questions were analyzed, they showed a decrease in mean post-test scores (69%) versus pre-test scores (75%). This could be due to a lack of participation in the post-test survey. The outcomes of these results could have been represented more accurately with a higher participation percentage. Due to the limited participation from subjects in the post-survey, results are inconclusive to say that the handoff tool is being utilized after implementation at this facility. The limitations of this study included a very small sample size. Due to the small sample size, no demographic data could be obtained to determine if anesthesia providers benefit from the handoff tool versus perioperative room nurses. This was to protect the confidentiality of the participants. Additionally, the handoff process depends on the individual's compliance. Since this is an exceedingly small facility in which providers have worked together for many years a reluctance to change factor is probable. The projects strengths were that it provided airway education to staff and a reference tool to teach new oncoming staff how to properly care for patient populations across the lifespan. Another strength of this study is that for oncoming SRNAs (student registered nurse anesthetists) the handoff tool is now visible to them to improve the flow and adequacy of their handoff report and continue to be used throughout the program. Standardized Handoff Tool 19 Our aim of implementing a standardized process for safe PACU handoff was completed, further research needs to be conducted to determine effectiveness and whether the process continues to be utilized in practice. Additionally, our goal of improving confidence levels through airway education in PACU staff was met but needs further investigation and participation to determine the significance of improvement. Conclusion Utilizing a standardized handoff checklist has helped healthcare providers stay organized and improve efficiency in the transition of care for patients. The checklist is simply an aid that ensures no pertinent information is lost. However, with the diverse nature of different healthcare facilities, each with individual ways of operation, reluctance to change will always be a contributing factor to why a checklist is not used consistently. In the future, further studies at larger healthcare institutions are needed to assess the effectiveness of utilizing a standardized checklist in the handoff process. Standardizing the handoff process has been shown to improve the organization and adequacy of handoff reporting. Utilizing a standardized handoff tool can decrease errors related to miscommunication. Standardized Handoff Tool 20 References American Association of Nurse Anesthesiology. 2022. PostAnesthesia Care. Retrieved October 21, 2022 https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/postanesthesia-care-practiceconsiderations.pdf?sfvrsn=677a6ac5_10 American Association of Nurse Anesthesiology. (2020). AANA Professional Practice Manual. Retrieved April 4, 2022, from https://www.aana.com/practice/practice-manual Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International Dalal, P. G., Cios, T. J., DeMartini, T. K. M., Prasad, A. A., Whitley, M. C., Clark, J. B., Lin, L., Mujsce, D. J., & Cilley, R. E. (2020). A model for a standardized and sustainable pediatric anesthesia-intensive care unit hand-off process. Children (Basel, Switzerland), 7(9), 123. https://doi.org/10.3390/children7090123 Gibney, C. (2017). A needs assessment for development of the TIME Anesthesia Handoff Tool. AANA Journal, 85(6), 431437 Furstein, J. S., & Morey , B. J. (2023). Postanesthesia Care. In Pediatric anesthesia: A comprehensive approach to safe and effective care (pp. 140145). essay, Springer Publishing. Halladay ML, Thompson JA, Vacchiano CA. Enhancing the quality of the anesthesia to postanesthesia care unit patient transfer through use of an electronic medical recordbased handoff tool. Journal of Perianesthesia Nursing. 2018. Standardized Handoff Tool 21 Lambert, L. H. (2018). Improved Anesthesia Handoff After Implementation of the Written Handoff Anesthesia Tool (WHAT). AANA Journal, 86(5), 361370. Lowe, J. S. (2017). A high-fidelity simulation study of intraoperative latent hazards and their impact on anesthesia care-related handoff outcomes. AANA Journal, 85(4), 250255. Meersch, M., Weiss, R., Kllmar, M., Bergmann, L., Thompson, A., Griep, L., Kusmierz, D., Buchholz, A., Wolf, A., Nowak, H., Rahmel, T., Adamzik, M., Haaker, J. G., Goettker, C., Gruendel, M., Hemping-Bovenkerk, A., Goebel, U., Braumann, J., Wisudanto, I., Wenk, M., Zarbock, A. (2022). Effect of intraoperative handovers of anesthesia care on mortality, readmission, or postoperative complications among adults: The handicap randomized clinical trial. JAMA, 327(24), 24032412. https://doi.org/10.1001/jama.2022.9451 (Meersch et al., 2022) Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, L. E. (2017). Does checklist implementation improve quantity of data transfer: An observation in postanesthesia care unit (PACU). Open Journal of Anesthesiology, 7(4), 6982. https://doi.org/10.4236/ojanes.2017.74007 Randmaa, M., Engstrm, M., Swenne, C. L., & Mrtensson, G. (2017). The postoperative handover: A focus group interview study with nurse anesthetists, anaesthesiologists, and PACU nurses. BMJ open, 7(8), e015038. https://doi.org/10.1136/bmjopen-2016-015038 Standardized Handoff Tool 22 Shah, A. C., Oh, D. C., Xue, A. H., Lang, J. D., & Nair, B. G. (2019). An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units. Health Informatics Journal, 25(1), 316. https://doi.org/10.1177/1460458216681180 Sun, L. Y., Jones, P. M., Wijeysundera, D. N., Mamas, M. A., Bader Eddeen, A., & OConnor, J. (2022). Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery. JAMA Network Open, 5(2), e2148161. https://doi.org/10.1001/jamanetworkopen.2021.48161 The Joint Commission. Improving Americas hospitals: The Joint Commissions annual report on quality and safety. 2008. https://www.jointcommission.org/assets/1/6/2008_Annual_Report.pdf. Accessed June 11, 2018. 23 Appendix A: Review of Literature Citation Dalal, P. G., Cios, T. J., DeMartini, T. K. M., Prasad, A. A., Whitley, M. C., Clark, J. B., Lin, L., Mujsce, D. J., & Cilley, R. E. (2020). A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit HandOff Process. Children (Basel, Switzerland), 7(9), 123. https://doi.org/10.3390/children7090123 Gibney, C. (2017). A Needs Assessment for Development of the TIME Anesthesia Handoff Tool. AANA Journal, 85(6), 431437. Design & Level of Evidence Quality Improvement Project Level: 1 Population / Sample size n=x n=135 Major Variables Instruments/Data Collection Results Intensive Care Unit nurses and Intensivists Joint Commissions time out model as universal protocol for start of handoff to ensure a standardized sequence of handoff. Staff satisfaction surveys of handoff process and performance audits made to identify if any critical parts of handoff were missed. Standardized handoff improves efficacy and staff satisfaction with decreased missed information without increasing healthcare costs. Descriptive survey design to assess need for handoff tool. opinions on most essential components of handoff at 2 large teaching hospitals in Chicago. Peer handoff lacks consistency without at tool, 64% do not use systematic process. Standardized handoff tool improves communication Anesthesia providers Meta Analysis Level:4 n=82 Anesthesia providers, work experience, hours worked per week. Standardized Handoff Tool Lambert, L. H. (2018). Improved Anesthesia Handoff After Implementation of the Written Handoff Anesthesia Tool (WHAT). AANA Journal, 86(5), 361370. 24 Quality Improvement Level: 1 n = 26 CRNAs, Anesthesiologists, PACU Rns Priori Power analysis to determine adequacy of sample size TST power analysis for assessment of current handoff process, causes of insufficient handoffs, and to review handoff process after implementation of written handoff tool was created. WHAT handoff tool improved problem with insufficient handoff and improved patient satisfaction amongst anesthesia providers and PACU RNs. Lowe, J. S. (2017). A high-fidelity simulation study of intraoperative latent hazards and their impact on anesthesia care-related handoff outcomes. AANA Journal, 85(4), 250 255. Observational study Level: 4 n =58 Distraction, production pressure, noninteractive communication, inappropriately timed handoff. The human error theory was utilized to review archived video recordings of simulations. 81% of the handoff reports possessed distractions contributing to poor quality handoff. (47/58). 24% of handoffs reviewed that report was given at inappropriate times when focus should have been on other events. Meersch, M., Weiss, R., Kllmar, M., Bergmann, L., Thompson, A., Griep, L., Kusmierz, D., Buchholz, A., Wolf, A., Nowak, H., Rahmel, T., Adamzik, M., Haaker, J. G., Goettker, C., Gruendel, M., Hemping-Bovenkerk, A., Goebel, U., Braumann, J., Wisudanto, I., Wenk, M., Randomized Clinical Control Trial Level: 5 n=1817 Intraoperative handovers from anesthesia and no Intraoperative handovers given. Participants recruited if ASA 3 or 4 status undergoing elective surgery. 52% of patients who had intraoperative handoff given required ICU admission (P=.10). There were no statistically Standardized Handoff Tool 25 Zarbock, A. (2022). Effect of intraoperative handovers of anesthesia care on mortality, readmission, or postoperative complications among adults: The handicap randomized clinical trial. JAMA, 327(24), 24032412. https://doi.org/10.1001/jama.2022.9451 Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, L. E. (2017). Does checklist implementation Improve Quantity of Data Transfer: An observation in postanesthesia care unit (PACU). Open Journal of Anesthesiology, 7(4), 6982. https://doi.org/10.4236/ojanes.2017.74007 CrossSectional observational study Level of evidence: 4 N=60 Randmaa, M., Engstrm, M., Swenne, C. L., & Mrtensson, G. (2017). The postoperative handover: a focus group interview study with nurse anaesthetists, anaesthesiologists and PACU nurses. BMJ open, 7(8), e015038. https://doi.org/10.1136/bmjopen-2016-015038 Qualitative analysis Level of evidence: 5 n= 23 Mortality, hospital readmissions, post-operative complications, anesthesia provider training. Anesthesia providers, surgical staff Different Perceptions and priorities amongst focus groups: focus areas include RN perspectives of handoff vs anesthesia providers perspective. Handover quality Retrospective analysis of multicenter with randomized testing utilizing HandiCAP trial. significant differences in hospital length of stay between non-handover group and handover group. A checklist was created and placed at every recovery suite bedside and required to be adhered to. Quantity of reporting handoff items were measured 60 pre checklist and 60 post checklist items. SBAR vs WHO SURGICAL CHECKLIST: Focus group interviews Analysis completed by moderator and sub moderator 5 categories emerged from interviews conducted: labeled with code Anesthesia staff consistently omitted reporting off surgical information, plans. Implementation of a physical checklist increased overall data transfer. Insecurity when information is transferred can impair quality of handoff. Need for a shared understanding amongst anesthesia and recovery RNs on priority of interventions. Standardized Handoff Tool 26 placed into subcategories Reine, E., Aase, K., Raeder, J., Thorud, A., Aarsnes, R. M., & Rusten, T. (2021). Exploring postoperative handover quality in relation to patient condition: A mixed methods study. Journal of clinical nursing, 30(7-8), 10461059. https://doi.org/10.1111/jocn.15 650 Observational mixed methods Level of Evidence: 5 Quantitative data N=109 Shah, A. C., Oh, D. C., Xue, A. H., Lang, J. D., & Nair, B. G. (2019). An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units. Health informatics journal, 25(1), 316. https://doi.org/10.1177/1460458216681180 Meta analysis Level 4 n=79 Anesthesia providers and pacu nurses Qualitative n=48 Qualitative data: Type of Surgery, ASA status, type of anesthetic, Anesthesia providers, attending physicians, ICU personnel engaging in ICU handoff after patients underwent surgery. Quantitative: content of verbal reporting and handover tasks Two different PACUs observed in. the handoff process utilizing the SBAR handoff checklist by two observers with the post-op handoff tool over a 1 year period Data collected from Anesthesia Information Management Systems (AIMS) and Smart Anesthesia Manager system to acquire real time data adding an informatics tool to facilitate handoff. A pilot observational study by medical students used to evaluate provider use of checklist. A pre-and postsurvey sent to handoff participants. 46% of handovers had interruptions Electronic handoff resulted in more present and engaging handoff with less focus on numbers when utilizing an electronic handoff tool. Standardized Handoff Tool Sun, L. Y., Jones, P. M., Wijeysundera, D. N., Mamas, M. A., Bader Eddeen, A., & OConnor, J. (2022). Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery. JAMA Network Open, 5(2), e2148161. https://doi.org/10.1001/jamanetworkopen.2021.48161 27 Retrospective cohort Level 4 N=102,156 Adult patients undergoing cardiac or thoracic surgery between 20082019 Length of surgery, presence of cardiogenic shock Heart failure symptoms, who had full transition of care by providers intraoperatively. CorHealth Ontario medical records obtained and reviewed with ICES administrative health databases. @ sample t-tests and Wilcoxon rank sum test to compare data. Handover during intraoperative cardiac surgery is associated with increased risk of 30-day mortality and 1-year mortality. 28 Appendix B: PRISMA diagram Standardized Handoff Tool 29 Appendix C: Theoretical Framework Standardized Handoff Tool 30 Appendix D: SWOT Analysis Standardized Handoff Tool 31 Appendix E: PowerPoint Presentation ANESTHESIA HANDOFF & AIRWAY MANAGEMENT OF SPECIAL POPULATIONS BY: HALEY SCROGGHAM & CARRIE FALASCA Standardized Handoff Tool 32 Standardized Handoff Tool 33 Standardized Handoff Tool 34 Standardized Handoff Tool 35 Standardized Handoff Tool 36 Appendix F: IRB Approval Letter  ...

... 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Simulation-Based Training for Student Registered Nurse Anesthetists Managing Malignant Hyperthermia Hilda Aveja Marian University Leighton School of Nursing Project Chair: Date of Submission: Lee Ranalli, DNP, CRNA April 22, 2024 2 Table of Contents Abstract............................................................................................................................................4 Simulation-Based Training for Managing Malignant Hyperthermia...............................................5 Background .........................................................................................................................5 Problem Statement...............................................................................................................6 Needs Assessment ...............................................................................................................6 Literature Review.............................................................................................................................6 Search Methodology............................................................................................................7 Importance of Simulations...................................................................................................7 Benefits of Malignant Hyperthermia Simulations...............................................................8 Use of Cognitive Aids in Simulations.................................................................................8 Theoretical Framework...................................................................................................................9 Aim and Objectives ......................................................................................................................10 SWOT Analysis.............................................................................................................................11 Methods .........................................................................................................................................12 Project design.....................................................................................................................12 Setting................................................................................................................................12 Population..........................................................................................................................13 Instructional Design...........................................................................................................13 Measurement Instruments..................................................................................................14 Data Collection..................................................................................................................15 Ethical Considerations/Protection of Human Subjects Results.........................................16 Results ............................................................................................................................................17 Key Action Checklist.........................................................................................................17 Scoring of the Tests...........................................................................................................17 Knowledge Improvement..................................................................................................18 Knowledge Retention........................................................................................................18 Discussion......................................................................................................................................20 3 Conclusion ....................................................................................................................................21 References .....................................................................................................................................22 Appendix A....................................................................................................................................25 Appendix B....................................................................................................................................26 Appendix C....................................................................................................................................29 Appendix D....................................................................................................................................30 Appendix E....................................................................................................................................31 Appendix F....................................................................................................................................38 Appendix G....................................................................................................................................39 Appendix H....................................................................................................................................40 Appendix I.....................................................................................................................................41 4 Abstract Background: Malignant hyperthermia is a disorder of the skeletal muscle that can present as a hypermetabolic response to triggering agents. Anesthesia providers frequently administer these triggers in the operating room. Therefore, it is imperative for providers to receive comprehensive education on malignant hyperthermia. Simulations help ensure their competence in the event of encountering a crisis. Purpose: This projects purpose was to improve malignant hyperthermia knowledge among student registered nurse anesthetists (SRNAs) at a small university in the Midwest through a lecture and simulation of a crisis. Methods: The universitys SRNAs were invited to participate in this project via email. The project consisted of an educational intervention through a lecture and simulation, which took place in the universitys simulation center. Qualitative data was collected with malignant hyperthermia key action checklist. The investigator also collected qualitative data using a pretest and post-test interventional design. Implementation: Ten educational sessions provided to participants (n = 32). Participants took a pre-test to assess their baseline knowledge. Then, they received a lecture, simulation, debrief, and post-test one. Post-test one was given to assess knowledge improvement. Six to eight weeks later, participants received an email to take post-test two, which assessed knowledge retention. Conclusion: Participants collectively received a mean score of 29.1 out of 30 on the key action checklist. The pre-test was assessed against each post-test using a paired samples t-test. Participants showed knowledge improvement from the pre-test to the post-test one (p > 0.05).This knowledge improvement was retained from the pre-test to post-test two (p > 0.05). Keywords: malignant hyperthermia, simulation, mock drill, anesthesia, anesthetist, SRNA, 5 Simulation-Based Training for Managing Malignant Hyperthermia Malignant hyperthermia (MH) is an autosomal dominant disorder of the skeletal muscle that presents as a hypermetabolic response when individuals are exposed to a triggering event (Rosenburg et al., 2007). Triggers for MH-susceptible patients include potent volatile anesthetics (such as sevoflurane, desflurane, and isoflurane), depolarizing neuromuscular blocking agents (such as succinylcholine), and in rare occasions, heat or exercise (Rosenburg et al., 2007). The incidence of MH is rare, but it has the potential for fatal consequences (Rosenbaum et al., 2015). Background The incidence of MH is estimated to range from 1:10,000 to 1:250,00 anesthetics (Rosenbaum et al., 2015). Because MH is a rare event, there is a lack of clinical experience in treating it among anesthesia providers. Anesthesia providers should be the first to recognize MH in the operating room (OR). Nevertheless, any clinician who works where MH-triggering drugs are administered should be able to recognize the signs and symptoms of the disorder. Signs and symptoms can include muscle rigidity, tachycardia, tachypnea, increased production of carbon dioxide, increased consumption of oxygen, acidosis, hyperthermia, rhabdomyolysis, and hyperkalemia (Rosenbaum et al., 2015). These symptoms are related to the bodys hypermetabolic state. Rapid recognition and treatment are vital to improving patient outcomes and reducing mortality risk. Rapid and efficient treatment of MH requires an interdisciplinary approach with effective leadership. Poor communication and team interactions have been shown to lead to poor outcomes in many settings, including the OR (Christian et al., 2006). A coordinated team effort is vital for the prompt treatment of MH. As such, it is necessary to ensure the competency of 6 clinical staff. The American Association of Nurse Anesthesiology (AANA) (n.d.) recommends ensuring clinical team competency through regular training and mock drills. Problem Statement Simulation is a safe and controlled learning environment that effectively teaches handson skills and improves knowledge retention. In healthcare settings, mock drills serve as an invaluable way of replicating rare real-life scenarios, ensuring clinician readiness and confidence if such cases present themselves in the clinical setting. The purpose of this project was to improve MH knowledge among student registered nurse anesthetists (SRNAs) at a small university in the Midwest through a lecture and simulation of an MH crisis. The simulation would theoretically improve the SRNAs knowledge and understanding of how to manage and treat patients with MH. The efficacy of this intervention was evaluated through a pre-test prior to the MH lecture, a post-test immediately following the simulation, and a follow-up post-test six to eight weeks after the simulation. Needs Assessment Providing healthcare professionals with simulation experiences of low probability, highimpact risk scenarios like an MH crisis can allow them to practice managing these scenarios in safe environments. Simulations allow them to learn from their mistakes without harming patients. Consequently, this could lead to improved clinician responses in the clinical setting. A university in the Midwest with a newer nurse anesthesia program has an excellent simulation center for its students. However, it was noted that while the program curriculum covered MH in multiple lectures, it was not covered in simulation. Implementation of an MH lecture concurrently with a simulated MH crisis was still necessary. Literature Review 7 Search Methodology The purpose of this literature review was to examine the current state of literature as it pertains to perceptions of MH simulations and their effectiveness. The databases used to perform the literature search were PubMed and CINAHL. The searches we conducted using the following BOOLEAN phrase "malignant hyperthermia" AND "simulation" AND "education OR training. The key words being malignant hyperthermia, simulation, education, and training. The search in PubMed was completed on November 29, 2022, and it initially yielded 25 results. The results were reduced to 13 documents by filtering in texts that were from 2012 to 2022, studies related to humans, and articles in the English language. The search in CINAHL was completed on November 7, 2022, and it yielded 17 results. The results were reduced to 9 by the use of the same filters used in PubMed. Of the total 42 articles 2 were duplicates. Therefore, 40 articles were screened for eligibility. Subsequently, 11 articles were excluded because they did not relate to MH and simulations. Overall, 10 full text articles were retrieved and assessed for eligibility and all 10 are included in this literature review. Articles older than 10 years were considered if used as a reference in multiple studies retrieved. A PRISMA Flow Diagram for the search methodology is found in APPENDIX A. Importance of Simulations During the literature review, multiple studies assessed the significance of simulation to clinical practice. Many of these studies concluded that simulations allowed participants to experience low-frequency clinical events without risking harm to patients (Bashaw, 2014; Cain et al., 2014; Mullen & Byrd, 2013). Bradshaw (2014) noted that simulation allowed participants to improve their performance. A similar conclusion was also made in studies conducted by Thompson et al. (2017) and Henrichs et al. (2002). These studies showed that their participants 8 reported an increased sense of preparedness for high-stress events such as MH. Matsco et al. (2020) and many studies reported a positive reaction from their participants. Furthermore, the positive reaction led to the implementation of additional simulations (Matsco et al., 2020). Although simulations were found to be an essential tool in experiencing low-frequency events, multiple drawbacks/limitations were identified in the literature. In many of the studies identified, the simulations were provided by employers to their employees or by schools to their students. This is important because the cost of the simulation is usually covered by the business entity to meet the needs of the company instead of the individual. Cannon-Diehl et al. (2014) noted that simulations are an important tool that can be used in continuing education for nurse anesthetists. However, the high cost of simulation technology can limit the development of highfidelity simulation by many smaller/low-cost educators. Several studies assessed the value of simulation in relation to low-frequency events. However, the data in relation to MH remains preliminary. More data needs to be collected within this realm, particularly as it relates to the benefits of an interdisciplinary MH simulation and its effects on collaboration, communication, and knowledge retention. Benefits of Malignant Hyperthermia Simulations Only two studies identified in the literature focused solely on MH simulation-based training (Gallegos & Hennen, 2022; Schaad, 2017). Both of these studies noted that MH simulations improved clinical knowledge and competency. Additionally, Schaad noted that simulation-based training enhanced communication among team members. This is particularly important in regard to MH. During an MH episode, prompt recognition and treatment are crucial. Staff need to be able to communicate and delegate roles appropriately. Use of Cognitive Aids in Simulations 9 Two of the studies identified evaluated the role of cognitive aids (Gallegos & Hennen, 2020; Hardy et al., 2020). Both noted that using a checklist during an MH simulation greatly improved participant adherence to critical steps and guidelines. These two studies highlight the importance of developing effective visual aids and encouraging their use in simulation and real life. The literature matrix is found in APPENDIX B. Theoretical Framework Theoretical frameworks can be used to support and guide new research. The NLN Jeffries Simulation Theory serves as a guide for nurse educators to develop, implement, and evaluate simulation-based education (Cowperthwait, 2020). The theory delineates seven key elements: context, background, design, facilitator/educational practices, participant, simulation experience, and outcomes (Jeffries et al., 2015). 1. Context involves an understanding of how many factors affect a simulation. These can include the environment in which the simulation takes place, the purpose of the simulation, and the evaluation criteria. 2. Background involves elements that are embedded within the context. Background includes resource allocation, goals, expectations of the simulation, and how the simulation fits within a larger curriculum. 3. Design involves the actual development of a simulation and describes key elements such as specific learning objectives, planned facilitator responses, role assignments, simulation flow, and briefing/debriefing strategies. 4. Facilitator and educational practices explain a facilitator's extensive role in the simulation's progression. Facilitators must be able to respond to participant needs by 10 prebriefing participants, adjusting the simulation based on its progression, providing appropriate cues, and debriefing following the simulation. 5. Participant describes how simulation participants affect the simulation. Participant attributes such as age, gender, level of anxiety, self-confidence, and level of preparedness will all affect the simulation. 6. Simulation experience should account for an environment that is learner centered in which learners can be interactive and collaborate. For the simulation to be successful there needs to be trust between the facilitator and participants. This will allow for participant buy-in and promote engagement. 7. Outcomes are divided into three areas: participant, patient, and system outcomes. Research commonly focuses on assessing participant outcomes such as knowledge, confidence, or behavior improvement. However, this theory can also guide research in other ways, such as evaluating patient safety outcomes or organizational cost effectiveness. The NLN Jeffries Simulation Theory served as the theoretical framework for developing this projects simulation-based training for SRNAs managing MH. The theory describes how context and background affect the project. As such, proper planning permitted project members to make changes that provided for the best simulation experience. Furthermore, the theory delineates simulation facilitator and participant attributes conducive to a successful learning environment and simulation experience. These are all concepts that were relevant to developing a successful MH simulation. For a visual representation of this theory please see APPENDIX C. Aim and Objectives 11 This project aimed to improve SRNAs' education and knowledge retention of MH. Consequently, SRNAs' response to MH in the clinical setting should improve, leading to increased patient safety. The main objective was to provide SRNAs with a comprehensive lecture on MH followed by a simulated MH crisis. During the crisis, they would be able to implement knowledge learned in the lecture. The simulation would cover managing the patients status, adjusting the anesthetic, reconstituting/administering dantrolene and other drugs, and placement of charcoal filters. The simulation and debrief session would also allow participants to note the importance of using visual guides and maintaining effective communication. Ultimately, the success of the educational intervention was tested using a pre-test, initial post-test, and follow-up post-test. The goal was to show an improvement in the post-test scores compared to the pre-test scores. SWOT Analysis A SWOT analysis was performed for this project to assess the project for opportunities. For a visual representation of the SWOT analysis please see APPENDIX D. Stakeholders in this project included the author, the university, MH-susceptible patients, and SRNAs. Simulation-based education provides an excellent opportunity for SRNAs to practice managing an MH crisis, all while ensuring patient safety remains uncompromised. Possible threats to this project included poor participant involvement, poor data collection, and facility unwillingness to implement the simulation. However, with the support of the anesthesia faculty, there was strong organizational support. Some possible weaknesses of this project could have been poor resource allocation, lack of MH simulation equipment, and busy student schedules. Potential opportunities for improvement were allocating supplies from medical 12 companies so that a more authentic simulation could be provided. This project presented an opportunity to educate SRNAs on MH and demonstrate that simulation-based training can potentially improve patient care. Methods Project Design This quality improvement project was centered around an MH educational intervention. The project gathered qualitative data through a pre-test and post-test interventional design. The post-test results were then analyzed to assess participants knowledge improvement and retention. The primary aim was to enhance SRNAs education on MH and consequently improve their recognition of and response to MH. Pre-test o Established MH knowledge baseline MH lecture MH crisis simulation Simulation debriefing session Post-test one Evaluated for MH knowledge improvement Post-test two (six to eight weeks later) o Evaluated for MH knowledge retention Setting This project took place in a simulation center for nurse anesthesia at a small private university in the Midwest. The simulation center contained two mock OR suites with high fidelity mannequins. The simulation took place in one of the mock ORs. This allowed SRNAs to 13 use a mannequin, anesthesia machine, OR supplies, and monitors with visual/auditory feedback. Population The sample was a convenience sample of SRNAs from the university. SRNAs from all cohorts were invited to attend. The exclusion criteria were any participant who could not participate during the whole lecture or simulation. The investigator sent several emails inviting all SRNAs to attend. A total of 32 SRNAs participated in the pre-test, lecture, and simulation. Of the initial 32 participants, only 31 completed post-test one. 18 participants took post-test two. However, only 12 of the 18 tests could be linked to their pre-test and post-test one. Below, readers will find a table representation depicting the age range, anticipated graduation year, and sex of the participants who took the tests. Pre-test (n=32) Demographics Count % of sample 20-30 years old 20 62.50% 30-40 years old 12 37.50% 2024 2 6.25% 2025 7 21.88% 2026 23 71.88% Male 8 25.00% Female 24 75.00% Post-test 1 (n=31) Demographics Count 20-30 years old 30-40 years old 2024 2025 2026 Male Female % of sample 20 64.52% 11 35.48% 2 6.45% 7 22.58% 22 70.96% 7 22.58% 24 75.00% Post-test 2 (n=12) Demographics Count 20-30 years old 30-40 years old 2024 2025 2026 Male Female 9 3 0 1 11 4 8 % of sample 75.00% 25.00% 0.00% 8.33% 91.66% 33.33% 66.66% Instructional design The MH lecture (APPENDIX E) was developed based on current MH knowledge. The resources used included Millers Anesthesia, 8th edition (Gropper & Miller, 2020), Clinical Anesthesia, 8th ed. (Barash et al., 2017), Obstetrics Anesthesia (Chestnut et al., 2020), and the Malignant Hyperthermia Association of the United States (MHAUS). MHAUS is a leading professional organization that promotes optimum care and scientific understanding of MH (Malignant Hyperthermia Association of the United States, n.d.). The lecture covers the pathophysiology of the disease, diagnostic criteria, and treatment options. The lecture was 14 assessed by Dr. Lee Ranalli, CRNA and DNP chair of this project, for face validity. The lecture was presented in person to SRNAs, and time was allotted for questions. Ten lectures were provided from February 12, 2024, to February 15, 2024. Ten education sessions were provided to ensure maximum attendance. After each lecture, an MH crisis simulation took place. The MH scenario was based on typical clinical presentations discussed in the lecture. The specific case details can be found in APPENDIX F. The simulation occurred in one of the universitys ORs with a high-fidelity mannequin and anesthesia machine. The OR was also equipped with continuous auditory and visual feedback vital signs. SRNAs had access to medical supplies and equipment during the simulated case. There were mock charcoal filters to practice placing them on the breathing circuit during simulation, and educational Ryanodex formulations were also available to practice reconstituting the drug. During the simulation, the performance of each group of participants was observed, and key tasks/actions were documented in a checklist. These were documented so that the investigator could provide feedback to each group during the debriefing sessions. During the debrief, participants were also able to share their thoughts on the experience. Measurement instruments One pre-test and two post-tests were given. All three tests were identical. Once participants agreed to partake in the project, they were asked a few demographic questions. These questions included age range, gender, and anticipated graduation year. Additionally, the tests contained five knowledge-based questions covered in the MH lecture. The knowledgebased questions remained the same in the pre-test and post-tests to allow for comparison and evaluation of knowledge retention. These tests were assessed for face validity by Dr. Ranalli. This test can be found in APPENDIX G. 15 During the simulation, participant groups were observed for technical tasks being performed. The tasks were assessed with a key action checklist. The checklist consisted of tasks that are critical in the treatment of a patient experiencing an MH crisis. Groups were expected to perform these tasks. The observer noted when tasks were met, partially met, and unmet. The group's overall performance was discussed in the debrief session. The debrief covered areas in which the group performed appropriately and areas that needed improvement. The checklist was assessed for content validity by Dr. Ranalli. See APPENDIX H for the key action checklist created. The creation of this checklist was influenced by Murray et al.'s (2005) checklist and key action scoring system for simulation exercises. Data Collection Participants were recruited for this project by the investigator via an email invitation. The email invitation included a link to sign up for the MH simulation. Recipients of this email included SRNAs from all cohorts at the university. Attendance of the education and simulation was voluntary. The educational intervention took place February 12-15, 2024. Ten educational sessions were held with groups of one to five participants. During simulation days, data was voluntarily collected before the lecture via an anonymous Qualtrics link to the pre-test, during the simulation via a key action checklist, and after the debriefing via an anonymous Qualtrics link to post-test one. Six to eight weeks following the simulation, two additional emails were sent to the SRNA cohorts inviting them to click on an anonymous Qualtrics link to take post-test two. Post-test two was the last data collected from participants. Informed consent was provided to participants in attendance. Individuals were informed of this project's purpose, aim, and objectives via the invitational email before initiating the pre-test. They were informed that their participation in the project was voluntary. If they 16 chose not to participate or wished to withdraw from the project at any time, there would be no consequences. The investigator provided participants with an email address and phone number that they could use to contact the investigator with any questions, concerns, or needs related to this project. The pre-test was given to participants in the lecture room via a scannable QR code that led them to the test. The investigator gave them the pre-test prior to the lecture. Following the lecture and simulation, participants received post-test one. Participants found the link to the test via a scannable QR code. This test was assessed for knowledge improvement. Six to eight weeks after the education, participants received post-test two via an anonymous Qualtrics link. Post-test two assessed for knowledge retention. These tests were used to assess a participant's knowledge improvement and retention. Data was also collected via direct observation during the simulation. This data was recorded using the key action checklist. Ethical Considerations/ Protection of Human Subjects The identity of participants was kept private and protected. For data collection purposes, participants were asked to provide the last four digits of their student ID number or any four-digit code they could remember before taking the pre-test and post-tests. These four-digit codes were used to link tests. All participants anonymity was protected. The project creator cannot access participants identities with the last four digits they provided. Additionally, only the project creator had access to their individualized data to protect their identity further. The university only had access to aggregate data. Data was transferred from Qualtrics to Microsoft Excel for evaluation purposes, and it was kept on a password-protected computer that was stored in a safe and secure location. 17 IRB approval from Marian University was attained prior to implementing this project. This is found in APPENDIX I. Results Key Action List Ten groups participated in the simulation experience. The groups consisted of one to five participants, comprising 32 participants. Their actions were observed and scored during the simulation using a key action checklist. Groups fully meeting an action warranted three points, partially meeting an action warranted two points, and not meeting an action warranted one point. The maximum number of points the ten groups could collectively earn in each category was 30. The mean score for each category was 29.1 (95% CI[28.6-29.6]). Table one shows how the ten groups scored in the key action checklist.. Table 1 Malignant Hyperthermia Checklist Met: 3pts 1. Call for help & notify surgeon 2. Get MH cart, code cart, cooling measures, call MHAUS 3. Discontinue triggering agent; continue IV sedation 4. Hyperventilate the patient with 100% FiO2 5. Increase fresh gas flow 10 L/min 6. Insert activated charcoal filters 7. Administer dantrolene 8. Administer bicarbonate 9. Monitor core temperature 10. Control patient temperature appropriately 11. Monitor and treat arrythmias 12. Maintain urine output > 1-2 mL/kg/hr with foley catheter 13. Monitor blood gases, electrolytes, CK 14. Analyze coagulation studies 15. Transfer to ICU & monitor 24-48 hours 10 groups Partially Did not meet: met: 2 pts 1 pt Collective points 30 10 groups 30 9 groups 1 group 9 groups 10 groups 9 groups 9 groups 10 groups 10 groups 9 groups 9 groups 1 group 1 group 1 group 1 group 1 group 8 groups 2 groups 8 groups 9 groups 9 groups 1 group 1 group 1 group 1 group 29 29 30 29 29 30 30 29 28 28 27 29 29 Scoring of the Tests The three tests were scored from zero to five points (0-100%). Participants received zero points if they answered a question incorrectly and one point if they answered a question correctly. 18 Knowledge Improvement A total of 32 participants took the pre-test, which was given before the lecture and simulation to establish baseline knowledge. Immediately following the simulation debrief session, participants were invited to take post-test one. Only 31 of these participants took posttest one. The post-test one was given to compare its results to the pre-test. The mean scores of both these tests were evaluated using a paired t-test. The mean score achieved by participants taking the pre-test was 2.5 points. Meanwhile, the mean score achieved by participants taking post-test one was 4.5 points. The data showed that the mean score from the pre-test to post-test one increased by 2 points (95% CI [1.52-2.5]). This was a statistically significant improvement (p <0.05). Tables two and three show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests. Table 2 Column1 Post-test 1 Pre-test Mean 4.580645161 2.5483871 Variance 0.31827957 1.38924731 Observations 31 31 Pearson Correlation -0.14391726 Hypothesized Mean Difference 0 df 30 t Stat 8.211184815 P(T<=t) one-tail 1.81828E-09 t Critical one-tail 1.697260887 P(T<=t) two-tail 3.63657E-09 t Critical two-tail 2.042272456 Table 3 Differences Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 2.0322581 0.2474988 2 2 1.3780148 1.8989247 -0.689778 0.3470417 5 0 5 63 31 0.5054599 Knowledge Retention Of the 32 participants who took the pre-test, only 12 took both post-tests. The mean scores of the pre-test, post-test one, and post-test two were compared to assess MH knowledge retention among these 12 participants. 19 The mean score of the participants taking the pre-test was 3.2 points. The mean score of post-test one was 4.5 points. While the mean score of post-test two was also 4.5 points. Table 4 shows these four mean scores. Table 4 n=12 Mean Pre-test Post-test 1 Post-test 2 3.166666667 4.5 4.5 When comparing the mean score of the pre-test versus post-test two, there was an average improvement in scores of 1.3 points (95% CI [0.83-1.83]). This improvement was statistically significant (p <0.05). Tables five and six show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests Table 5 Column1 Mean Variance Observations Pearson Correlation Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail Post-test 2 Pre-test 4.5 3.1666667 0.636363636 1.0606061 12 12 0.663940002 0 11 5.93295879 4.91565E-05 1.795884819 9.8313E-05 2.20098516 Table 6 Difference Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 1.3333333 0.2247333 1 1 0.7784989 0.6060606 0.924 0.6679521 3 0 3 16 12 0.4946346 Interestingly, the mean scores of the post-test one and post-test two were the same: 4.5 points. However, this was not statistically significant (p =1). The data showed that the difference between the mean score of post-test one and the post-test two was 0 (95% CI [-0.72-0.72]). Please refer to tables seven and eight below. Tables seven and eight show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests. 20 Table 7 Column1 Mean Variance Observations Pearson Correlation Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail Table 8 Post-test 2 4.5 0.636363636 12 -0.169030851 0 11 0 0.5 1.795884819 1 2.20098516 Post-test 1 4.5 0.454545455 12 Difference Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 0 0.3256695 0 0 1.1281521 1.2727273 -0.3367347 0 4 -2 2 0 12 0.7167937 Discussion Collectively, the groups scored fairly well during the simulation. When responding to crisis situations, team dynamics are essential. In a study conducted by Christian et al. (2006), they found that a major contributor to compromising patient safety was communication breakdown and information loss. During the MH lecture, participants were encouraged to use closed-loop communication, delegate roles and tasks, and use visual aids while in the simulation. There were several key actions during the simulations that groups missed due to poor communication and lack of using an MH checklist/guide. Coordinated team efforts are necessary for the prompt treatment of an MH crisis. Teams should always set roles and delegate tasks during a crisis. Additionally, they should ensure closed-loop communication with frequent check-ins to see what tasks have been done and what still needs to be done. Simulation-based training is an effective means of improving educational outcomes. Participants taking the pre-test had a mean score of 64%. Following the lecture, simulation, and debrief session, participants who took post-test one had a mean score of 90%. This improved mean score remained at 90% in post-test two despite being taken six to eight weeks following the 21 simulation. These results support the proposal that simulation-based training will improve MH knowledge and retention among SRNAs. While this project has provided valuable insights, it is important to acknowledge its limitations. The small sample size, with a higher attendance rate from first and second year SRNAs, is a factor that needs to be addressed in future studies. It is crucial to replicate this project at other healthcare centers and schools to further validate its findings and ensure its applicability across different settings. Conclusion It is well known that MH is a rare event in the OR. Many anesthetists may never experience an MH crisis throughout their careers. For this reason, it would be beneficial for healthcare centers that provide MH triggering agents to implement regular intervals of MH crisis simulations. These simulations could provide clinicians with the opportunity to practice treating crises in a safe setting, improving their overall knowledge of MH. 22 References American Association of Nurse Anesthesiology. (n.d.). Malignant Hyperthermia Crisis Preparedness and Treatment. https://www.aana.com/docs/default-source/practice-aanacom-web-documents-(all)/malignant-hyperthermia-crisis-preparedness-andtreatment.pdf?sfvrsn=630049b1_8 Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., Ortega, R., Sharar, S. R., & Holt, N. F. (2017). Clinical anesthesia (8th ed.). Lippincott Williams & Wilkins. Bashaw, M. (2016). Integrating simulations into perioperative education for undergraduate nursing students. AORN Journal, 103(2). https://doi.org/10.1016/j.aorn.2015.12.017 Cain, C. L., Riess, M. L., Gettrust, L., & Novalija, J. (2014). Malignant hyperthermia crisis: Optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN Journal, 99(2), 300311. https://doi.org/10.1016/j.aorn.2013.06.012 Chestnut, D. H., Wong, C. A., Tsen, L. C., Ngan Kee, W. D., Beilin , Y., Mhyre , J. M., & Bateman , B. T. (2020). Chestnut's obstetric anesthesia: Principles and practice (6th ed.). Elsevier. Christian, C. K., Gustafson, M. L., Roth, E. M., Sheridan, T. B., Gandhi, T. K., Dwyer, K., Zinner, M. J., & Dierks, M. M. (2006). A prospective study of patient safety in the operating room. Surgery, 139(2), 159173. https://doi.org/10.1016/j.surg.2005.07.037 Cowperthwait, A. (2020). NLN/Jeffries Simulation Framework for simulated participant methodology. Clinical Simulation in Nursing, 42, 1221. https://doi.org/10.1016/j.ecns.2019.12.009 23 Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia preparedness training: Using cognitive aids and emergency checklists in the perioperative setting. Journal of PeriAnesthesia Nursing, 37(1), 2428. https://doi.org/10.1016/j.jopan.2020.09.020 Gropper, M. A., & Miller, R. D. (2020). Miller's anesthesia (9th ed.). Elsevier. Hardy, J.-B., Gouin, A., Damm, C., Compre, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and non-technical performance for simulated malignant hyperthermia management. Anaesthesia Critical Care & Pain Medicine, 37(1), 1723. https://doi.org/10.1016/j.accpm.2017.07.009 Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries Simulation Theory: Brief Narrative Description. Nursing Education Perspectives, 36(5), 292293. https://doi.org/10.5480/1536-5026-36.5.292 Malignant Hyperthermia Association of the United States. (n.d.). What is MH / MHAUS? MHAUS. Retrieved January 15, 2023, from https://www.mhaus.org/about/what-is-mhmhaus/ Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the Operating Room. The Journal of Continuing Education in Nursing, 51(11), 523527. https://doi.org/10.3928/00220124-20201014-09 Murray, D., Boulet, J., Kras, J., McAllister, J., & Cox, T. (2005). A simulation-based acute skills performance assessment for anesthesia training. Anesthesia & Analgesia, 101(4), 11271134. 10.1213/01.ane.0000169335.88763.9a Mullen, L., & Byrd, D. (2013). Using simulation training to improve perioperative patient safety. AORN Journal, 97(4), 419427. https://doi.org/10.1016/j.aorn.2013.02.001 24 National League for Nursing. (2022). Tools and Instruments. National League for Nursing. Retrieved January 13, 2023, from https://www.nln.org/education/teachingresources/tools-and-instruments Rosenberg, H., Davis, M., James, D., Pollock, N., & Stowell, K. (2007). Malignant hyperthermia. Orphanet Journal of Rare Diseases, 2(1). https://doi.org/10.1186/17501172-2-21 Rosenberg, H., Pollock, N., Schiemann, A., Bulger, T., & Stowell, K. (2015). Malignant hyperthermia: A Review. Orphanet Journal of Rare Diseases, 10(1). https://doi.org/10.1186/s13023-015-0310-1 Schaad, S. (2017). Simulation-based training: Malignant hyperthermia. AORN Journal, 106(2), 158161. https://doi.org/10.1016/j.aorn.2017.06.008 Thompson Bastin, M. L., Cook, A. M., & Flannery, A. H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American Journal of Health-System Pharmacy, 74(6), 424429. https://doi.org/10.2146/ajhp160129 25 Appendix A Screening Identification Identification of studies via databases Records identified from: PubMed (n =25 ) CINAHL (n= 17) Total (n=42) Records removed before screening: Records removed for other reasons PubMed (n= 11) CINHAL (n= 9) Records screened PubMed (n= 24) Cinhal (n=16) Records excluded (n= 11) Duplicate records removed (n= 2) Reports sought for retrieval (n = 10) Reports not retrieved (n= 0) Reports assessed for eligibility (n = 10) Included Reports excluded: n= 0 Studies included in review (n= 10) *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ 26 Appendix B Citation Bashaw, M. (2016). Integrating simulations into perioperative education for undergraduate nursing students. AORN Journal, 103(2). https://doi.org/10.1016/j.aorn.2015.12.017 Cain, C. L., Riess, M. L., Gettrust, L., & Novalija, J. (2014). Malignant hyperthermia crisis: Optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN Journal, 99(2), 300311. https://doi.org/10.1016/j.aorn.2013.06.012 Cannon-Diehl, M. R., Rugari, S. M., & Jones,, T. S. (2012). High-fidelity simulation for continuing education in nurse anesthesia. AANA Journal, 80(3), 191196. Research Design & Level of Evidence Qualitative evaluation; level 3 Population / Sample size n=x 9 Quality improvement project; Level 5 33 Needs assessment non experimental study, level 3 22 Major Variables Instruments / Data collection Results -Only nursing roles -Mock OR -Class hours-> convenience sample -High fidelity simulator -Clinical faculty members who hold CNOR certification led the simulation experience. n/a Debrief QSEN competencies discussed Simulation allows students to experience untoward patient outcomes without jeopardizing patients, especially for lowvolume, high-risk scenarios. Also allowed student nurses to evaluate and improve their performance in a safe learning environment without risking harm to actual patients. Clarifying who performs the different tasks in an MH emergency simulation improves efficiency in an emergency response. Simulation is a recognized educational method that can be used to help personnel acquire the skills necessary to respond efficiently to an MH event. -Age -Years of practice -Practice setting -Experience with HFS Debrief and observational Pilot survey The higher cost of simulation technology, as opposed to traditional teaching and learning methods, has been cited as a barrier to simulation. 59% of nurse anesthetists polled would pay extra to experience HFS for continuing education. High-risk, low frequency events such as cardiopulmonary resuscitation, anesthesia machine mishaps, and malignant hyperthermia 27 Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia preparedness training: Using cognitive aids and emergency checklists in the perioperative setting. Journal of PeriAnesthesia Nursing, 37(1), 2428. https://doi.org/10.1016/j.jopan.2020.09.02 Qualitative study; level 3 13 Hardy, J.-B., Gouin, A., Damm, C., Compre, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and nontechnical performance for simulated malignant hyperthermia management. Anaesthesia Critical Care & Pain Medicine, 37(1), 1723. https://doi.org/10.1016/j.accpm.2017.07.009 Henrichs, B., Rule, A., Grady, M., & Ellis, W. (2002). Nurse anesthesia students perceptions of the anesthesia patient simulator: a qualitative study. AANA Journal, 70(3), 219225. Prospective study; level 2 24 Qualitative study; level 3 12 Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the Operating Room. The Journal of Continuing Education in Nursing, 51(11), 523527. Descriptive simulation evaluation; level 5 n/a -previous experience with cognitive aid education -participants different work backgrounds/ experience -previous experience with simulations -years of experience -clinical experience with MH Scenario, group size, time Post implementation survey -staff scheduled to work -staff unaware simulation taking place before hand Observational timeline collection, debrief with theme collection Performance evaluation tool based on SFAR guidelines Observation, journal entries, focus group interview were cited as highly effective events to be used in simulation The use of simulated exercises incorporating cognitive aid tools was the best way to ensure participants would include critical MH treatment steps in their response and retain this information in the long term Anesthesiologists use of the MH checklist during a simulation session widely improved their adherence to guidelines and non-technical skill Disadvantages include the lack of reality, lack of knowledge on handling crisis events, possibility of fixation errors, and the presence of anxiety. Advantages include improved critical thinking and decisionmaking skills, increased confidence, and improved clinical preparation. Results can be used to assist instructors in improving the students learning experiences a positive reaction from this in situ training led to additional simulation requests for the education department. 28 https://doi.org/10.3928/0022012420201014-09 Mullen, L., & Byrd, D. (2013). Using simulation training to improve perioperative patient safety. AORN Journal, 97(4), 419 427. https://doi.org/10.1016/j.aorn.2013.02.001 Descriptive simulation evaluation; level 5 n/a n/a Observational recording Schaad, S. (2017). Simulation-based training: Malignant hyperthermia. AORN Journal, 106(2), 158161. https://doi.org/10.1016/j.aorn.2017.06.008 Thompson Bastin, M. L., Cook, A. M., & Flannery, A. H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American Journal of Health-System Pharmacy, 74(6), 424429. https://doi.org/10.2146/ajhp160129 Nonexperimental study; level 3 >100 n/a Verbal feedback Qualitative research; level 3 20 -Clinical scenario -PGY1 vs PGY2 Survey Simulations safely identify problems that can happen during emergencies and allow staff members to evaluate their performance and improve it without risking harm to patients Improved clinical knowledge and competency relate. SBT enhanced communication among team members. Simulation training increased pharmacy residents selfreported preparedness for highstress, high-impact clinical scenarios and medical emergencies 29 Appendix C 30 Appendix D Project SWOT Analysis 31 APPENDIX E 32 33 34 35 36 37 38 Appendix F Case: Natalie Maye Age: 17 year old Gender: female Weight: 55 kg Height: 160 cm Surgery: left rotator cuff repair Anesthesia: general Surgical position: sitting Past medical history: none No known allergies Full code Family history: Father: (43 years old) no anesthesia history Mother: (40 years old) history of appendectomy at 14 years old without complications No siblings 39 Pre-test/ post-test one/ post-test two Appendix G 1. Select 2 early clinical signs of MH: a. Hyperthermia b. Tachypnea c. Elevated EtCo2 d. Hyperkalemia 2. What is the initial dose of dantrolene used to treat malignant hyperthermia? a. 0.25 mg/kg b. 2.5 mg/kg c. 0.15 mg/kg d. 1.5 mg/kg 3. What 2 conditions are NOT associated with malignant hyperthermia? a. Multiminicore disease b. Duchenne muscular dystrophy c. RyR1 myopathy d. Becker muscular dystrophy 4. Select the 2 answer choices that are NOT a trigger for malignant hyperthermia? a. Halogenated anesthetics b. Depolarizing muscle relaxants c. Non-depolarizing muscle relaxants d. IV anesthetics 5. Which test can be used to test for malignant hyperthermia susceptibility? a. Dibucaine inhibition test b. Caffeine halothane contracture test c. Total serum tryptase d. MTHFR gene detection 40 Appendix H Malignant Hyperthermia Checklist 1. 2. 3. 4. 5. 6. 7. Met Call for help & notify surgeon Get MH cart, code cart, cooling measures, call MHAUS Discontinue triggering agent; continue IV sedation 10 Hyperventilate the patient with 100% FiO2 Increase fresh gas flow 10 L/min Insert activated charcoal filters Administer dantrolene 9 8. Partially Met Did Not Meet Notes 10 9 1 (did not start TIVA until further prompted) 1(only increased FiO2) 10 9 9 Administer bicarbonate 9. Monitor core temperature 10. Control patient temperature appropriately 10 11. Monitor and treat arrythmias 9 12. Maintain urine output > 1-2 mL/kg/hr with foley catheter 8 13. Monitor blood gases, electrolytes, CK 8 14. Analyze coagulation studies 9 15. Transfer to ICU & monitor 24-48 hours 9 1 (placed incorrectly) 1 (mixed drug and forgot to give it until further prompted) 1-2 meq/kg (corrects lactic acidosis) 10 9 1 (cold IVF & lavage) 1 (did not teat life threatening arrythmia promptly with CPR) 2 (forgot to place foley and give diuretics until further prompting) 1 (did not order labs until further prompted) 1 (did not order labs until further prompted) 1 (needed prompting) Cools to 38 degrees then stops Cold IVF Lavage Icepacks Procainamide 15 mg.kg IV Lidocaine 2 mg/kg IV No CaCH blocker life threatening hyperkalemia IV hydration Mannitol 0.25g/kg Lasix 1 mg/kg IV 1 (late treatment of hyperkalemia) High k= 5-10mg/kg CaCl Insulin 0.15 u/kg +D50 1mL/kg Hyperventilate 41 Appendix I  ...

... From Abstract to Practical: Fostering Student Engagement with Existential Theory Noelany Pelc, Ph.D. Department of Psychological Science and Counseling 3200 Cold Spring Road, Indianapolis IN 46222 Theories of Personality: PSY 335 Background: Theories of Personality is an upper-level course focusing on the study of major theoretical paradigms of personality, including psychoanalytic, trait, biological, learningcognitive and humanistic models. Students examine human commonalities and differences, as well as hereditary and experiential influences on emotion, cognition and behavior. Challenge: Existential theory is often one of the most challenging paradigms for students to operationalize, as it is rooted in philosophy and contrasts heavily with previous units focusing on biological, neurological, trait, and psychodynamic theories that are covered in more depth in high school and pre-requisite courses. Class Composition: Majority pre-health students (e.g., nursing, pre-med, counseling, physical therapy) seeking to work in applied settings. Framing of Existential theory: A response to dehumanization and recent innovations leading to industrialization, isolation, and re-defining of human meaning (Kierkegaard, 1843; Nietzsche, 1870). Psychological distress issues not only from our biological genetic subtrate (a psycho-pharmacologic model), not only from our struggle with suppressed instinctual strivings (a Freudian position), not only from our internalized significant adults who may be uncaring, unloving, neurotic (an object relations position), not only from disordered forms of thinking (a cognitive-behavioral position), not only from shards of forgotten traumatic memories, nor from current life crises involving ones career and relationship with significant others, but also-but also-from a confrontation with our existence (Yalom, 2008, p.180) Key questions: What is the nature of existence? How does it feel to exist? What does it mean to exist? Sequence of Theories: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) Introduction to Personality Personality Assessment Trait Theories Biological Perspectives Evolutionary Perspectives Psychodynamic Perspectives Neo-Psychodynamic Perspectives Existential and Humanistic Perspectives Cultural Perspectives Cognitive/Experiential Perspectives Stress and Coping Figure 1. Sequence of theories introduced in course. Framework- Constructionism and phenomenology Guidelines for engagement Inclusivity, self-selection, privacy, and levels of participation Day 1: Active Large Group Experimentation Activity Set-Up: Students are asked to create large discussion circle and provided with Guidelines for Engagement with verbal buy-in. Students are asked a series of questions that focus on: 1) intrapersonal; 2) interpersonal; 3) existential themes, in sequence. Intrapersonal Goal: This module was designed to facilitate an exploration of Existential theory in personal and professional settings. Theoretical Framework Four Ultimate Concerns: Freedom Isolation Meaning Mortality Activity Sequence and Prompts Interpersonal Sample questions: Existential Figure 2. Diagram of nested themes. How are you feeling right now? What is important to you? How might others describe you? What do others miss when they see you? What does society say about you? (positive and negative) What do you think your purpose in life is? When do you feel like you are most connected to your purpose? Day 3: Application and Case Study Spectrum of experiences: mortality, fear, isolation, joy, awe, freedom, autonomy and responsibility Case study application and links to health professions Cross cultural perspectives Self-reflection Class Case Study and Small Group Work: Students are provided are shown What Really Matters at the End of Life,(TED, 2015) which is a TED talk by a palliative physician discussing themes of health, mortality, compassion, empathy, and the human experience. Small groups complete a handout framing existential themes within the healthcare setting and prompting personal reflection (See Figures 5 & 6). Figure 5. Screenshot of TED Talk shown. Activity Engagement: Students are given 7-8 slips of brightly colored paper and instructed to write their responses to the questions posed (see note about selfselection and levels of participation). Theyre instructed to crumple their slips, toss them to the middle and retrieve one. Invited to read slips to the group or offer their own reactions. The procedure is repeated 7-8 rounds with facilitated discussion during each cycle. Figure 6. Screenshot of hand-out provided. Themes around freedom, isolation, meaning and mortality are annotated. Group Process: Group is engaged in themes that link narratives, common experiences and sense of connection to each other. Figure 7. Screenshot of Hazda Tribe member interview. Inclusivity, self-selection, privacy and levels of participation: Student slips are anonymous, can write/share only what feels comfortable, and have choice as to whether they read slips or share reactions. Many students indicate that they prefer to process internally, which is supported. Minimum of 10 students recommended to prevent identification. Day 2: Examine Content Existential theoretical tenets and core theorists Rogerian stance and person-centered attending skills Eastern perspectives, First Nations perspectives, and systemic barriers Foundational Content: Provided via PowerPoint, video clips, and framed within historical contexts and movements, while exploring bias. Themes are contrasted and compared with a brief documentary around cultural differences in meaning, purpose, and joy for a remote tribe (Fearless and Far, 2021; Figure 7). Feedback, Outcomes, and Future Directions Outcomes: Students generate links to other helping coursework, integrate co-curricular themes of dignity of the individual, social justice, empathy and compassion (Franciscan Values), students indicate using person-centered attending skills and feel more comfortable addressing existential themes. Student-reported scores over 7 semesters (n= ~210 students): 1-5 (1 indicating not effective or engaging, 5 indicating highly effective and engaging) (m= 4.93). Figure 3. Diagram of humanistic/existential skills that can be used across fields. Figure 4. First Nations perspective of commonlytaught hierarchy of needs in Western psychology. References: Available on supplemental handout. Modifications: Over last 6 years, modified activity to provide greater privacy (e.g., slips vs responding out loud), engaged the whole group (vs 1 student volunteer at a time), and included a health-related focus to facilitate career application for class composition.  ...

... Rounding out FYE with a Dose of Holistic Health Dr. Matthew Walsh & Dr. Holly Gastineau-Grimes Marian University Background Who: First year students What: 3 credit course required for TJP When: Spring Semester M/W 2pm 3:15pm T/Th 11am 12:15pm Where: Library Auditorium and Classrooms How: Face-to-Face (Lectures and Seminars) Day 1 = Large Lecture Day 2 = Seminar Discussion Days 3 & 4 = Classroom Instructions and Activities 8 Domains of Well-Being Intellectual Financial Occupational Physical Emotional Social Spiritual Environmental Research Question Results Does HWB-110 improve self-perceived wellness ratings for students? Total well-being and every domain saw significant improvement after students engaged in the class Methods Individual Wellness Domains: Student Average Score 40 35 Students completed personal assessment for each domain of wellbeing at the start and end of semester 10 questions for each domain with scores ranging from 10-40 Paired t-tests were used for all students who completed all questions in each pre and post surveys and could be paired (n=70) Qualitative data was collected about each domain, delivery method, assignments, and overall course 30 25 20 15 10 5 0 Intellectual Occupational Financial Physical Domain Average Scores Pre-Test Domain Pre-Test Mean Post-Test Mean Emotional Social Spiritual Environmental Domain Average Scores Post-Test Mean Difference Significance Confidence Interval Cohens d Total 243.67 272.06 28.38 .001 18.099-38.669 .663 Intellectual 31.42 34.04 2.63 .001 1.886-3.364 .834 Occupational 29.23 32.42 3.190 .001 1.934-4.446 .601 Financial 29.09 33.06 3.971 .001 2.776-5.166 .798 Physical 31.08 33.86 2.779 .001 1.867-3.690 .727 Emotional 29.63 33.27 3.643 .001 2.545-4.740 .791 Social 33.03 35.37 2.343 .001 1.470-3.215 .640 Spiritual 31.86 34.76 2.907 .001 1.876-3.938 .672 Environmental 27.97 31.80 3.826 .001 2.635-5.017 .772 I would say this course was an amazing course to be in! The lectures and discussions really pushed me to take time for myself so that way I can better myself and better understand what I need.  ...

... An Attempt to Unlock Critical Thinking: Nursing Escape Room for BSN Students Marie Beechy MSN, RN, CNE, PMH-BC Background Student engagement in the learning experience has long been a goal of nursing educators. This escape room activity was developed in response to observations as well as student feedback that students were struggling to translate classroom theory into clinical practice. This is especially true in mental health nursing where students can have limited clinical experiences due to safety concerns on the unit. A recent study completed on the use of a nursing simulation escape rooms for BSN students suggests that the use of an escape room can impart experiential learning with critical skills needed to work as an effective member of a team. (Valdes, McKay, & Sanko, 2021) This activity offers BSN students a unique opportunity to apply theoretical knowledge to real-life scenarios, foster critical thinking, collaborate, and apply clinical skills in a secure setting. Student Responses Activity Outline The escape room learning experience was a timed activity that simulated a situation in which the student nurses would be caring for a patient with Bipolar disorder. They were divided into groups of four to five and given a debriefing prior to entering the room. There were a series of seven tasks that had to be completed before they could break-out of the room. The tasks included: Display of basic knowledge of the condition Patient assessment Medication management Medication administration Patient intervention Care planning prioritization Safety risk evaluation The activity took an average of 30 minutes from pre-brief to debrief. Each group was given feedback on performance postactivity. They also provided a self-reflection on the activity. Loved how the escape room was reality-based and had a lot of questions that required us to utilize our critical thinking skills in a quick manner. The escape room was a unique way to practice the information, so it helped me reinforce the topics I knew and highlight the ones I wasnt so strong on The sequential process necessary for getting out of the room was very similar to a real-life situation with a bipolar patient. The chaotic nature of an escape room is very similar to the care of mental health patients as well I really liked how the escape room followed the nursing process and it took you through every step from initial assessment to drug administration for implementation. Conclusion and Future Considerations This activity was implemented in Fall 2023 and has run 2 semesters. Student feedback has been overwhelmingly positive as it relates to the activity and the development of critical thinking and patient care management skills. Current plans include the implementation of another escape room SIM on eating disorders based on student feedback as well as the use of an evaluation tool to measure outcomes. Anticipated Learning Outcomes 1.Clinical Assessment: Outcome: Improve mental health assessment skills by participating in a simulated scenario. 2.Interdisciplinary Collaboration: Outcome: Enhance teamwork and communication with peers to solve mental health challenges. 3.Critical Thinking: Outcome: Develop problem-solving abilities to address complex mental health crises and puzzles. 4.Crisis Management: Outcome: Acquire and apply crisis intervention skills for safely managing mental health crises. 5. Inclusivity Outcome: Reduce stigma related to care of the patient with mental illness References Valdes, B., Mckay, M., & Sanko, J. S. (2021). The Impact of an Escape Room Simulation to Improve Nursing Teamwork, Leadership and Communication Skills: A Pilot Project. *Simulation & Gaming*, *52*(1), 54-61. [https://doi.org/10.1177/1046878120972738](https://doi.org/10.1177/1046878120972738)  ...

... Mastery Practice Exercises: Positive Impact on Student Performance Scott Houser M.Ed. College of Arts and Sciences, Department of Biology B225 Human Anatomy Spring 2024 52 students Large lecture format Exams are multiple choice Build Quizzes Build large item banks Organize banks by objective Mastery practice draws from 100s of different questions Protocols Six attempts Highest score is kept Treat it like a test Take notes on what you got wrong Locked out for one hour Impact on Scores Strong Correlation p = 0.57 to 0.72 Lecture MPs and Lab exams p = 0.81 MARIAN UNIVERSITY ----------Indianapolis--------- Student Response To Mastery Practice: The anatomy lab course enhanced my ability to understand material in the anatomy lecture class. This course was well-organized and planned. The combination of quizzes, mastery practice activities, hands-on learning, lectures and presentations helped to implement studying habits which are extremely critical for this class. I appreciate my professor for providing these activities and planning strategies. marian.edu  ...

... Field Notes from NSG 211 From Weeding to Blooming: Cultivating Bioscience Success in Nursing Mackenzie Flynn,MSN,CPNP-AC/PC NTER ENT ONS: I V I Strategies intertwined to increase self-directed, active, and collaborative learning. A non-traditional course resource, smosis, a collection of engaging and concise auditory-visual videos of complex science topics built on a framework of self-directed learning, increased student engagement. Students completed assignments before the content was covered by watching required videos and free-hand answering content questions. This self-directed preparation facilitated active learning methodologies during classroom lecture hours. Examples of activities included collaborative quizzing, writing exam questions, concept mapping, think-pairshare, case studies, and utilizing the Anatomage Table. This course was fortunate to participate in the MU pilot undergraduate teaching assistant program (Aaliyah Mikels). Aaliyah's presence greatly enriched the course culture, including well-attended "Weekly Recap" group learning sessions. pen weekly library faculty office hours provided small group collaborative content review opportunities O O . CHALLENGE: Bioscience courses in nursing education (anatomy, physiology, pathophysiology, chemistry, and microbiology) have historically been called "weed out" classes. Nursing student attrition is highest during the 100 and 200-level bioscience sequence, propagating the workforce shortage and lack of diversity in nursing. Despite "weeding," 300 and 400-level students and practicing nurses struggle to integrate bioscience concepts into practice, hindering academic and professional success and ultimately affecting patient outcomes. These overlapping challenges create a need to maintain academic standards while minimizing the historical barriers in education. To address these challenges, the Nursing Pathophysiology course (NSG 211) at Marian University introduced several innovative strategies to cultivate a mindset of growth, learning, and achievement. References: Bennett, M. P., Lovan, S., Smith, M., & Elllis-Griffith, C. (2021). Nursing's leaky pipeline: Barriers to a diverse nursing workforce. J Prof Nurs, 37(2), 441-450. https:// doi.org/10.1016/j.profnurs.2020.05.002 Colsch, R., Lehman, S., & Tolcser, K. (2020). State of pathophysiology in undergraduate nursing education: A systematic review. Journal of Nursing Education and Practice, 11(3). https://doi.org/10.5430/jnep.v11n3p11 Horiuchi-Hirose, M., Fukuoka, T., & Saeki, Y. (2023). Integration of anatomy and physiology into nursing practice as perceived by undergraduate students and registered nurses: a scoping review. BMC Nurs, 22(1), 270. https://doi.org/10.1186/s12912-023-01436-0 Moots, H. and Sorrel, B. (2023, January 23). Empathy in Teaching (Episode No. 4) [Audio podcast]. In Nursing Education Insights. https://evolve.elsevier.com/education/expertise/ faculty-development/empathy-in-teaching/ Mueller-Burke, D., Bindon, S., Akintade, B., & Idzik, S. (2024). The AACN essentials: An intentional framework for successful implementation. Journal of Professional Nursing, 52, 62-69. https://doi.org/10.1016/j.profnurs.2024.03.009 I love am able manner. in a using to It the view is different traditional Anatomage what also I more am fun table learning to mix environment/setting lecture in a for classroom in class a more things than because in format up the I visual and learn I like it helps I learned really the in me like class better activities understand the week the group [Undergraduate TA because me it helps information so I understand and because before. can I what also tutoring weekly "dumb learning] down" the better remember it. I love the in class activities because they help me learn in a more hands-on, engaging way as compared to my other classes where most if not all of the class time is being spent listening to lectures. I also like how the class prep assignments give me a peek into what I will be learning the next week, so rather than being overwhelmed with new information I am already somewhat familiar with the topic. FUTURE GOALS: Although evidence and student feedback affirm the effectiveness of active learning methodologies, there is also a notable inclination among students in this course for traditional PowerPoint presentations and lectures. Nursing education has traditionally placed a significant emphasis on testing. Consequently, students often prioritize memorization and rote learning to enhance their chances of regurgitation for success. Future goals for the course include improving assessment methods to align with active learning principles. The goal is to enhance students' perception and appreciation of active learning strategies. Additionally, integrating elements of metacognition fosters students' awareness and understanding of their learning processes within an active learning framework. This goal aligns with an upcoming shift in nursing education required by the American Academy of Colleges of Nursing (AACN) to transition to competency-based assessment in 10 domains necessary for beginner competency in nursing practice.  ...

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... ONLINE LEARNING is EASIER IN MARIAN ONLINE PROGRAMS Engaging Diverse content Asynchronous Assortment of Offerings Variety of assignments Varied course design Active Example Online Course Foster Deep Understanding Active Assignment Examples Meaningful Content Application Peer to Peer Interactions/Collaboration Supported Scaffolded Content Program Resources Hubs Diverse and Veteran Faculty Interactive Example Program Resource Hub Faculty Interaction Personalized Feedback Opportunities for Student Reflection Experiential Current Content Experienced Faculty Real-World Connections Clear Alignment of Objectives Partnership Agreement Online Course Planning Guide Launch and Orientation to Online Milestone 1: Course Design Milestone 2: Course Development Milestone 3: Review and Evaluation Templates and resources Multiple rounds of feedback Dedicated instructional design support and collaboration Course Reviews Each term and session, online courses are reviewed by team members Reviewed For: Internships Industry Professionals bring real-world context Rigorous Discussion Board Use Course Development Course Clarity Appropriate Updates University Initiatives Demo Video Tools utilized to ensure appropriate rigor Rigor Calculator Tool Info Improvements based on Student Feedback  ...

... Utilizing Cloud-based Coding Platforms to Teach Computer Programming Courses Mohammad S. Shirazi, Hansika I. Sirikumara E.S. Witchger School of Engineering, Marian University, Indianapolis ABSTRACT In this work, we present cloud-based integrated development environments (IDE) to teach computer programming courses. Traditionally, desktop-based programming environments are used for teaching computer programming courses. With the emergence of cloud-based systems, the online IDE tool can readily be utilized since they require minimum setup on the desktop computers. We utilized Replit and amazon web services (AWS) as two famous cloud-based environments to teach introduction to programming, and advanced programming courses in Fall 2023 and Spring 2024 semesters. We investigate and explore varied features of these tools and finally provide comparison with the traditional desktop-based IDE. Utilized Cloud-based Integrated Development Environments MOTIVATION & BACKGROUND Traditional coding platforms require setting up and installation of the software 1) Replit is an online IDE that allows users to create online projects called Repls. Replit originally supported over 50 programming language and uses the Nix package manager which allows users access to the entire package database. The on the local computers. With the advances in computer systems and network technologies, computers Replit was used in Fall 2023 to teach two sections of the Introduction to Programming (CST-150) courses. can be connected to the campus internet through wireless communication, and Utilized Replit Features cloud-based software tools to teach computer programming and science Creating a team of education for Marian University. courses. Creating two sections as different classes for the team. Advantages of using cloud-based programming software Adding students from each section to the team. Collaboration: students can edit, share, and comment the codes as a Creating lab assignments with test modules. team. Instructors can also access the codes, visualize their writing, and edit Pros: Accessibility. the code in real-time. Simplicity. Accessibility: students can edit, share, and comment the codes as a team. Easy to view and help students with their coding assignment. Instructors can also access the codes, visualize their writing, and edit them. Cons: Sometimes students confused some features of the software such as Version control: students can integrate version control systems (e.g., Git) completing the lab assignments with creating Repls to practice coding. to access and manage different versions of their codes over time. Automatic update: We dont need to worry about software updates since 2) AWS Academy is an educational program offered by Amazon Web Services. It supplies educational institutions with a features are automatically updated by the cloud-based servers connected structured curriculum and resources. The program focuses on teaching cloud computing concepts and AWS services. It includes hands-on labs and instructor-led training. The AWS academy features were used in Spring 2024 to teach the through the internet. Backup and recovery: Students dont need to worry about saving the Advanced Programming (CPE-246) course. coding assignments and not losing them due to hardware failure. The Utilized AWS Academy Features system automatically creates backup and recovers as needed which makes Creating a new course. the system quite reliable and safe. Add students as people to the course. Create Cloud9 environment to complete code assignments using C++ language. Pros: Accessibility. Easy to view the code and assist students with their coding assignments. Cons: The system is relatively slow when initiating the connection to the server for start time. The sharing code between students requires a shared environment and adding new users. Each student has limited credit to use the programming resources for free ($100). IDE Evaluation & Conclusion APPROACH The popular cloud-based software such as Replit and AWS Academy are utilized during the teaching of computer science and engineering courses at Marian University. The virtual programming classrooms are created, and students complete their assignments within the environment during the semester. Based on the instructors observation and students performance in the class, the utilized software are compared and evaluated with the traditional coding software such as visual studio code (VS Code). Research Question: What are the benefits of using the cloud-based system in comparison with traditional ones in practice while teaching the programmingrelated courses? Based on the course instructor's observation of software, the evaluation of the cloud-based IDE with traditional one (VS code) is as follows: Software Replit AWS Academy VS Code Ease of Use High High High Speed Medium Medium High Connectivity High Medium ----- Shareability High Medium Low In summary, if network connection is feasible, we suggest Replit. However, it is not recommended for real-time applications such as PyGame due to lack of speed in comparison with VS Code.  ...