TeamSTEPPS® Instructor Manual: Specialty Scenarios

Neonatal ICU

Specialty scenario for this guide.

Contents

Scenario 44
Scenario 45
Scenario 46
Scenario 47


Scenario 44

Appropriate for: Neonatal ICU
Setting: Hospital

 

At approximately 2100, the NICU nurse who is caring for a 26-week-old infant pages the on-call resident and tells him that she is concerned about the baby's color and that the baby is having more ABD episodes. The resident reluctantly goes to the bedside, examines the patient, and says he believes the infant is stable. Two hours later, the nurse contacts the resident and again expresses her concern that the baby "just doesn't look good.” The resident reassures the nurse and says he thinks the baby is fine. Three hours later, the nurse contacts the resident with the results from a blood gas that she obtained. The resident is upset because he did not order a blood gas and did not feel one was necessary. The results are 7.21/48/63/-10. The resident examines the patient again and is unconcerned. The nurse asks that the attending physician be called, but the resident refuses. At approximately 0530, the nurse calls the resident again, with another update and continued concern about the infant. When she finally asks the resident whether the staff attending is aware of the issues from overnight, the resident claims he is just about to call him. When the neonatologist arrives, he significantly alters the existing therapy, and the baby improves.

Instructor Comments

  • Successful use of Two-Challenge rule and advocacy.

Skills Needed

  • Situation monitoring. Mutual support.

Potential Tools

  • Two-Challenge rule, Advocacy/Assertion.

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Scenario 45

Appropriate for: Neonatal ICU
Setting: Hospital

 

The on-call third-year resident is sitting in the break room talking with the chief resident when both of their code pagers go off. They run to the ER. The chief resident arrives first and is receiving information about the patient while doing an exam on that patient. The on-call resident then reaches the room and, without assessing the patient or learning the history, begins calling out orders to the nurses. The residents give contradictory orders, and the ER staff becomes confused about whose orders they should follow. The residents begin to argue because each feels his plan of action is correct. Critical orders are not carried out because no one knows who is in charge. Ultimately, the on-call staff pediatrician arrives and takes over the code.

Instructor Comments

  • The case represents teamwork failure, a missing shared mental model, poor communications, and failure of conflict resolution.

Skills Needed

  • Team structure. Communication. Mutual support.

Potential Tools

  • Call-out, Handoff, Cross monitoring, Delegation, Collaboration, Advocacy/Assertion, Task assistance.

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Scenario 46

Appropriate for: Neonatal ICU
Setting: Hospital

 

A premature infant is scheduled for surgery to have his bilateral hernias repaired. Surgery is scheduled for 0700, and he is placed NPO after 0330. An IV is placed and prophylactic antibiotics are given, but no fluids are started. Surgery states they will start the fluids in the OR. Unfortunately, the surgery is delayed because the surgical team is involved with an emergency trauma case. At 0930, the nurse caring for the infant realizes that the infant is still NPO and on no IVF. D-stick is 30. The NICU team is notified; the infant is given a D10W bolus and then started on IVF.

Instructor Comments

  • This shows situation awareness, situation monitoring, and patient advocacy that resulted from a breakdown in communications.

Skills Needed

  • Situation Monitoring: Assess status of patient, assess progress towards a goal. Mutual support.

Potential Tools

  • Cross monitoring, Collaboration.

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Scenario 47

Appropriate for: Neonatal ICU
Setting: Hospital

 

In a level 2 NICU, the average census is five or six patients. There are only three ventilators available and one RT in house. The Infant Star ventilator is being used to give NCPAP to a 35–week-old infant with mild RDS; the second ventilator has just been used on a baby that has been transferred to another facility; and the third ventilator is out for repairs. After the second infant is discharged, the RT is asked to clean the Servo ventilator because that is the only other ventilator available to the NICU staff. Over the next 2 hours, the RT goes for his dinner and a smoke break. The RT is then called away to cover a CODE BLUE in the ER, which takes several hours. Afterward, he notes that he is behind on his regular rounds of giving nebulizer treatments and ventilator checks on the other patients in the hospital. At the end of his shift, a crash c-section is called; and the baby is delivered and intubated in the delivery room. The RT is called to the NICU to place the baby on the ventilator, which has not yet been cleaned.

Instructor Comments

  • The RT staff involved fails to exercise appropriate prioritization of tasks. The lack of the ventilator cleaning might have been recognized by other staff if they were using optimal situation awareness. In this case, a call-out or use of the Two-Challenge rule would have helped the RT recognize the appropriate priorities.

Skills Needed

  • Mutual support. Situation awareness.

Potential Tools

  • Call-out, Two-Challenge rule, Advocacy/Assertion, Conflict resolution.

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Current as of March 2014
Internet Citation: TeamSTEPPS® Instructor Manual: Specialty Scenarios: Neonatal ICU. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/neonatalicu.html