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Innovation in hemodialysis emergency training using high-fidelity simulation.

Introduction: High-fidelity simulation-based training is a profoundly effective educational tool for healthcare providers in which critical events are actualized without risk to patients. Simulation-based training provides situational awareness for low-frequency yet high-intensity events with an environment and philosophy of learning and safety. The multidisciplinary approach to simulation-based training has many benefits including skills development, competency and confidence enhancement, team building, collaboration, communication, and systems/environmental analysis, as well as needs and cultural assessments.

It is imperative that dialysis nurses are able to identify when their patients are at risk of dialysis-related complications/emergencies and implement appropriate and timely intervention. Confidence levels vary significantly among nurses when dialysis-specific emergencies arise. This is largely due to the infrequency of such events, as well as inadequate specialized training to prepare for them. These factors can act as barriers to the acquisition of confidence and competence, and erode already established resources.

Methods: Our pilot study included 14 renal nurse participants. Years of hemodialysis nursing experience ranged from six months to 16 years. All participants (13 registered nurses [RNs] and one registered practical nurse [RPN]) were hemodialysis nurses from the renal program at London Health Sciences Centre: 50% were from in-hospital acute centres and the remaining staff were from a shopping mall-based satellite unit. Each session involved four to five hemodialysis nurses. Three training sessions were offered, each lasting approximately three hours. Training scenarios were created based on typical hemodialysis-related emergencies. Training sessions took place in the simulation lab within the Canadian Surgical Technologies & Advanced Robotics (CSTAR) at London Health Sciences Centre using a high-fidelity simulator Laerdal SimMan 3G in conjunction with a "dummy" hemodialysis treatment using the Fresenius 5008 dialysis machine. Four scenarios were simulated, which included: hypoglycemia, intradialytic hypotension (IDH), cardiac arrest, and venous needle dislodgement. Debriefing sessions took place after each scenario lasting approximately 20 minutes. Participants were given a confidence survey using a 10-point Likert scale after the session was completed. They were asked to rate their confidence both before and after the training session for comparison.



Results: Confidence scores were proven to increase after the simulation-based training sessions. Scores increased by 2.1 points for the hypoglycemia scenario, 1.5 points for the IDH scenario, 2.8 points for cardiac arrest, and 2.8 points for the venous needle dislodgement scenario. Collectively, confidence scores increased on average by 2.3 points on the Likert scale. It is important to note those situations that occur less frequently (cardiac arrest and venous needle dislodgement) were the scores that increased the most, supporting the benefits of simulation-based training for low-frequency/high-intensity events. Narrative comments submitted by staff were positive, indicating that there is a prominent need and desire for simulation-based training in the dialysis setting, and it was felt that this should be a mandatory component of education for all dialysis nurses regardless of years of experience.

Outcomes: Nurse--Simulation-based training in dialysis will prove to be a successful tool if nurses experience increased confidence when handling dialysis related emergencies. Also, the early identification and appropriate treatment of emergencies led to reduced length of stay or transfers.

Patients--Patients will experience reduced anxiety levels and improved confidence in care during adverse events in the dialysis unit with a reduction in transfers/length of stay post dialysis.

Discussion: Simulation-based training adds a component of competency when high-risk situations arise in the dialysis setting and time is of the upmost importance. We believe that the implementation of such an educational program will not only improve the patient safety, but will also enhance desired health outcomes for patients receiving hemodialysis. Our pilot project was held in the controlled environment of CSTAR, which provided an opportunity for staff to be removed from the distraction of their familiar unit; however, there is also an immense benefit to moving into this familiar environment. An in-situ simulation-based training opportunity is now available, the benefits of which include the ability to identify cultural/environmental gaps and needs assessment for functionality and efficiency.

We are now planning the second phase of this project, which will take high-fidelity simulation on the road; in partnership with CSTAR, we will be travelling to each of our eight regional satellite dialysis partners to provide them with this rich learning opportunity using high-fidelity simulation for dialysis-specific emergencies. The evaluation and metrics for phase 2 will be available at the time of CANNT 2017.

Jarrin Penny, BSN, RN, CNeph(C), London, ON
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Author:Penny, Jarrin
Publication:CANNT Journal
Geographic Code:1CANA
Date:Apr 1, 2017
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