Using Declining Patient Condition Simulations in the Radiation Oncology Outpatient Setting to Improve Clinician Responses

Abstract

Patient acuity and the complexity of ambulatory procedures are increasing across the spectrum of healthcare in the United States. This trend is no different in radiation oncology, where patients experience emergent issues. While many of these issues can be prevented, thus avoiding emergency situations, most education only focuses on identifying and responding to the most emergent clinical situations. Patients who are declining are at increased risk of advancing to emergent conditions because of the lack of evidence-based guidelines to prevent further clinical decline. The purpose of this quality improvement project was to improve the knowledge and comfort level of the care team in responding to urgent patient care situations in the ambulatory radiation oncology setting. The authors hypothesized that institution of a formal educational program would lead to an improvement in comfort level in both identifying and managing declining patients. An inter-professional educational plan was developed to shift focus from emergent scenarios to focus on declining patients. As part of that education, simulations were developed using examples of actual clinical situations, and focused on preventing patients from further declining into emergent conditions. The plan included quarterly didactic, inter-professional education and hands-on simulations. Pre- and post-assessment surveys, using a 1-5 Likert scale measured comfort levels of clinicians before and after the intervention. Post intervention, results were statistically significant for the ability of team members to identify adverse reactions (Mean difference [MD] 0.76, p=.028), care for declining patients (MD .67, p=.044), manage airway decompensation (MD 0.93, p=.023), know their role in a crisis (MD 0.81, p=.009), understand the role of other team members (MD 0.73, p=.028), and know specific items used to intervene when a patient is in crisis (MD 1.55, p<0.001). There was no statistically significant difference in respondents’ comfort level in recognizing a deteriorating patient, caring for a patient who did not require code team assistance, or managing patients with seizures. However, all three measures demonstrated a trend towards improvement. Until recently, the focus in ambulatory settings had been the practice of emergencies and code blue scenarios. As patient acuity and care complexity increase in these settings, clinicians can benefit from review of urgent care and scenarios of patients deteriorating that focus on the broader scope of care. Results of this project indicate that, while educating interprofessional staff to recognize patients who are deteriorating is important, a focus on the importance of team dynamics is equally important. The implication of this project is that formal training on recognition and management of declining patients is beneficial in the ambulatory setting to build staff comfort.