DOES YOUR hospital have an in-house outpatient hospital clinic? If so, who responds to medical emergencies? Does the staff receive any crisis training?
Older patients with multiple comorbidities are at an increased risk for emergency events in outpatient clinics, and there is always a delay before well-trained emergency professionals arrive. Action taken during this time can contribute to improved patient outcomes. This article discusses the impact of emergency preparedness training on outpatient clinic staff in a large healthcare system.
The University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital is a 758-bed tertiary care facility with a well-established crisis response system. The medical emergency team (MET) responds to seven or more emergency medical crises every day. It includes designated nurse responders from the ICU, respiratory therapists, and critical care physicians. These professionals respond to crisis events, including all medical emergencies and cardiac arrests, in specific areas depending on geographic and service-related zones in three connected hospitals and outpatient clinics. In 2017, the MET responded to 2,720 emergencies, 124 of which were cardiopulmonary arrests. Of these, 34 were seen in the main clinic building, where visiting patients typically have multiple comorbidities.
To improve emergency preparedness on inpatient units, nurse educators developed a one-time 1.5-hour course, called The First 5 Minutes, to teach nurses the proper actions to take before the MET arrives.1 Additionally, a crisis training course that emphasized teamwork was developed for inpatient nurses to further enhance nursing responses in emergencies.2 However, no consistent training had been available for the outpatient clinic nurses, including those responsible for bringing the emergency cart and acting as the first emergency responders.
A 2013 study described the importance of administrative support in facilitating rapid response and promoting patient safety.3 Accordingly, UPMC Presbyterian Hospital's outpatient clinic nurses sought input from the institution's medical emergency response improvement team (MERIT), which included stakeholders such as physicians, nurses, respiratory therapists, pharmacists, administrators, and healthcare professionals from other disciplines. In conjunction with administration, the team decided the clinics required specific emergency training.
Seven 1-hour training sessions were held in the primary clinic between March 2017 and October 2018. The goal was to teach outpatient clinic nurses and other support staff how to manage medical emergencies before the arrival of the MET. The training was directed toward healthcare professionals from the endocrinology, pulmonology, infectious disease, dermatology, surgery, rheumatology, and trauma clinics.
Organizing training sessions
The training curriculum highlighted the importance of preparedness and the role of the clinic staff during emergencies. A literature review revealed a paucity of evidence describing and/or supporting consistent emergency response training in outpatient clinics. One 2014 study discussed the importance of precrisis training for dermatology offices, however, listing tasks associated with emergency response and recommending that specific responsibilities be assigned to personnel.4
The staff received training in their respective clinics to simulate real-life experience. Sessions began with the participants being asked about their last experience with a medical crisis. Their concerns focused on a lack of defined roles and responsibilities for clinic personnel and questions about designated leadership before the arrival of the MET. Information and training on these and other concerns were then disseminated to the clinic staff. After didactic training, the sessions concluded with hands-on practice in patient-care, application of cardiac monitor pads, basic cardiac monitor/defibrillator operation, and an overview of emergency cart equipment.
The clinic staff stabilizes the patient until the MET arrives to provide more advanced interventions. As such, the importance of rapid communication was stressed to provide details on the precise location of a medical emergency in the clinic, and specific personnel were designated to remain at the clinic entrance to direct the MET to the patient. Additionally, the Situation, Background, Assessment, and Recommendation (SBAR) tool was used to communicate quickly and effectively with emergency responders as they arrived.5
A 2018 study cited communication as vital in continuity of care and staff training for medical emergencies.6 Closed loop communication, which refers to acknowledging and confirming information as it was intended, remains an essential component of any team effort during emergencies.6,7 Additionally, UPMC Presbyterian Hospital emphasizes an “if you see something, say something” philosophy.
The sessions included a discussion on the responsibility for retrieving the emergency cart and a review of its contents. The nursing staff came from various positions and educational backgrounds, but assessing a patient's level of consciousness and the ABCs (airway, breathing, circulation) is within every nurse's scope of practice. The importance of quickly placing a pulse oximeter and, if applicable, administering supplemental oxygen and using a bag-valve mask for rescue breathing was stressed. Although suction was not readily available in every clinic, any healthcare professional could perform the tasks related to it. The use of suction and the operation of the emergency cart's portable suction were reviewed at length.
After discussing airway and breathing priorities, the application of cardiac monitoring pads and the use of the cardiac monitor/defibrillator were reviewed. Staff was given time to apply the pads and connect them to the cardiac monitor, and each nurse practiced defibrillation.
Documentation was reviewed (for example, obtaining and documenting vital signs and blood glucose levels). The sessions also covered the significance of simple but important tasks, such as removing furniture and other obstacles to provide 360-degree access to the patient, and supporting family members.
Feedback from the MET revealed confusion regarding who should remain with the patient when the MET arrived. The individual caring for the patient should remain with him or her, provide an SBAR report, and answer any additional questions from the emergency responders. A completed documentation form was distributed for review during training, and clinic leadership was urged to create a method to easily provide a health history from patient records (see Meeting challenges to ensure safe emergency care).
Feedback and results
A total of 80 clinic staff attended the seven courses. At the end of the session, the participants completed an evaluation tool developed by the course facilitators, who analyzed responses to the following four statements based on a four-point Likert scale (4 = strongly agree; 1 = strongly disagree):
- The training improved my ability to identify roles and responsibilities.
- I am comfortable knowing what to do in the first 5 minutes.
- I am confident using the SBAR tool with the MET.
- The training improved my ability to function as a member of a team during a crisis.
The scores denoted overall agreement with the statements, ranging from 3.4 to 3.8 with a mean of 3.6 (see Achievement of learning objectives). Each participant was asked to include any additional comments about the course.
Barriers and limitations
There were multiple barriers throughout the development and implementation of the training sessions. Hospital-based nurse educators encountered challenges with staff availability for training and stakeholder agreement on the goals and processes. Healthcare professionals from various educational levels and positions also needed training, which was adapted accordingly. Collectively, the participants included nurses, respiratory therapists, medical technicians, administrative assistants, and hospital leadership.
Many of the clinics did not own training equipment, so CPR manikins, SBAR posters, paperwork, and simulators for the cardiac monitor were brought in. Because only two emergency carts were available in the building, one had to be secured for access in all sessions. The nurse educators answered staff questions related to processes and identified equipment to be replaced and electronics to be updated. A list compiled after training detailed items to be replaced and questions to be reviewed.
The training sessions have been beneficial for clinic staff of all levels of experience. The low volume and infrequency of emergency calls is an obstacle that can affect competency, however, and ensuring frequent training to prepare new staff has been a barrier. Additionally, the MET and the outpatient clinics utilize different systems for electronic health records, which do not interface, so the most effective way to provide a patient's detailed health history to the MET remains a challenge.
Although each outpatient clinic is part of the hospital and receives emergency response from hospital emergency personnel, gathering and analyzing hard data has been challenging. In the future, MET responders will be aiming toward a more consistent process to obtain this information. Other freestanding clinics and physician offices may find further obstacles depending on their specific circumstances. For example, many physician's offices may not be connected with an acute care facility or have a dedicated MET. These facilities may have to call 911 to respond to medical emergencies.
Additional follow-up items were addressed with clinic and hospital leadership, including the availability of linens for the stretcher in transporting patients to the ED and an inventory of the contents of the emergency cart. It was suggested that linens be kept with the emergency cart, and the pharmacy was contacted regarding its contents. Additionally, a procedure for simultaneous emergencies was developed by leadership to ensure a cart was brought to each event.
Each training session raised new questions related to processes, and the team coordinated with leadership to facilitate resolutions. Recognizing the need for more hands-on practice and process improvement, the hospital-based nurse educators hope to continue to reinforce emergency response training in the outpatient clinics in the future. The MET also plans to incorporate debriefing sessions as a follow-up after an event, which may provide a more direct evaluation of the training sessions based on real emergency responses. Additionally, a pre-assessment evaluation tool will be beneficial in the future.
Training healthcare professionals and paraprofessionals simultaneously can be challenging due to differing educational preparation, roles, scopes of practice, and levels of expertise. Additional time is essential for some participants.
UPMC Presbyterian Hospital plans to reinforce the training sessions biannually to maintain staff competence in emergency situations. Ongoing review of emergency clinic events may guide future training needs.