Disasters such as earthquakes can interrupt healthcare delivery by forcing the evacuation of intensive care patients. Critically ill neonates are particularly vulnerable due to their complexity and thus can be difficult to safely and efficiently evacuate in a disaster. In general, most education surrounding this is based on lectures. This technical report describes the creation and use of a simulation-based curriculum focusing on the evacuation of a critically ill, septic neonate by a single nurse participant in the setting of an earthquake. This simulation provides learners the experience of expediently assessing safety in the setting of a disaster and prioritizing equipment when evacuating a critically ill neonate, which may provide a more realistic training environment than traditional lectures.
Unexpected catastrophic events such as earthquakes interrupt essential healthcare delivery via structural damage, flooding, and staff and supply shortages that force the evacuation of intensive care patients [1-2]. Critically ill neonates are some of the most vulnerable patients in disasters, given their often complex medical management involving multiple lines, airway maintenance, medications, thermoregulation, etc. . The purpose of this curriculum is simulation education of nurse-led evacuation of a critically ill neonate in the setting of a disaster. Effective evacuation of this simulated septic neonate requires knowledge of safe and efficient patient packaging and transport.
The primary goal of pediatric patient evacuation is to safely and effectively transport the patient. Given the critical nature of a septic neonate, it is important to ensure that the necessary equipment is transported to maintain the patient. Septic-intubated neonates who are hemodynamically unstable require antibiotics, intravenous fluids, vasopressors, and airway equipment for adequate therapy [3-4]. Along with critical care equipment, other vital materials for safe transport in a disaster are required such as patient identification.
The design of this simulation incorporated adult learning principles including allowing for active learning through participation and immediate feedback. This simulation allows participants to individually perform an environmental assessment in the immediate aftermath of an earthquake, practice communication via a repeat back, and demonstrate appropriate patient preparation for evacuation. At the conclusion of the scenario, facilitators crosscheck a list of items and review actions taken with medications, infusions, tubes, drains, and patient information.
This simulation case was developed to help nurses systematically prepare to evacuate a critically ill neonate as part of the pediatric nursing disaster curriculum. To differentiate this simulation exercise from standard hospital disaster curriculum, the authors entitled the case Evacuation of Vulnerable and Critical Pediatric Patients (EVAC). Through participation in this simulation, learners have the opportunity to practice communication with their charge nurse, assessment of the environment, themselves, and the patient in the event of an earthquake, as well as practice preparing the patient for evacuation by appropriately managing bedside patient equipment necessary for patient survival. Though it was originally developed for a target audience of pediatric nurses in the neonatal intensive care unit (NICU) or pediatric emergency department (PED) setting, it may be modified for other healthcare personnel that may be charged with evacuating a critically ill neonate, such as pediatric intensive care unit nurses or general emergency medicine nurses. Ideally, nurse participants should have prerequisite knowledge of general patient assessment, common healthcare communication tools, and understanding of general patient transport. Depending upon your targeted learners, it might be helpful to review these before the simulation [3-6].
A checklist (Figure 1) was created to help score pediatric hospital equipment needed to evacuate a critically ill neonate via a modified Delphi method by surveying experienced charge nurses from the neonatal intensive care unit and the pediatric emergency department, with a necessity ranking ranging from most critical equipment to not important equipment .
After the scenario is completed, facilitators may utilize the debriefing materials in Appendix A as a guide. Feedback on the case may be obtained verbally and via the evaluation form provided in Appendix B. Appendix C is optional and includes a slides-based didactic put together by the authors as supplemental to facilitator-led teaching and debriefing. We received feedback that it may be helpful for participants to have a checklist during the simulation or debrief provided and so Appendix D: EVAC Simulation Checklist Card was created for participants (may be printed front and back and downsized to identification (ID) card sized). Lastly, pediatric disaster communication terminology is provided in Appendix E for the instructor in preparation for the simulation case and to utilize in prebriefing and/or debriefing.
Primary Educational Objectives
By the end of this activity, learners will be able to:
1. Evaluate the post-earthquake environment by checking themselves, identifying hazards, and checking on their patients.
2. Efficiently organize appropriate materials for safe patient transport and evacuation.
3. Demonstrate effective communication while assessing a patient for evacuation during a disaster using standard communication tools such as SBAR (situation, background, assessment, recommendations) and closed-loop communication.
Brandon is a 15-day-old male who presented with fever and was found to have sepsis. He is intubated, receiving antibiotics, vasopressors, and intravenous (IV) fluids. The patient is on full monitors and has on a diaper and hospital gown. After receiving sign-out on this patient, an earthquake occurs and the nurse participant is expected to prepare the patient for evacuation.
Anticipated interventions include assessment of the environment/self/patient, clear communication, and collecting appropriate items for patient evacuation. The patient’s vital signs remain static throughout the case, and the participant has five minutes to complete the evacuation.
Learner Critical Actions
1. Assessing self, environment, and patient
2. Utilizing clear communication with the charge nurse
3. Collecting at least all essential items on a checklist
4. Preparing to evacuation in less than five minutes
5. Disconnecting the patient from the ventilator and utilize handbag masking
6. If utilizing an embedded participant parent, clear and open communication to the parent
Instructor: Bedside Nurse who transitions into the role of Charge Nurse
If other instructors are available, one may play the bedside nurse and the other may play the charge nurse.
If available, an embedded participant may play the patient’s parent, so that communication with the parent may be assessed.
The simulation scenario is designed as a curriculum for a sole learner with a target audience of nurses that care for critically ill neonates, such as pediatric emergency medicine (PEM) or NICU nurses. There are no prerequisites for nurses prior to participating in this case. Depending on the nurse’s background, facilitators may provide optional background material on disasters and patient evacuation (Appendix C), as well as common healthcare communication tools (Appendix E). Educational materials may be provided either before or after the scenario. The facilitator plays the role of the charge nurse giving patient sign-out as well as informs the participant of the earthquake and provides instructions regarding evacuation. In our curriculum, facilitators were physicians; however, the scenario may be led by nurses in educational roles, such as unit nursing educators, charge nurses or nursing managers, thus improving the realism of the scenario.
1. Introduction to pediatric disaster training
· Emergency Nurses Association (ENA). ENPC: Emergency nursing pediatric course: Provider manual. 4th ed. Des Plaines, IL: Emergency Nurses Association; 2012.
2. General knowledge about pediatric evacuation and earthquake preparedness
· Monteiro S, Shannon M, Sandora TJ, Chung S. Pediatric Aspects of Hospital Preparedness. Clinical Pediatric Emergency Medicine. 10(3) 216-28; 2009.
· FEMA. Earthquake Preparedness: What every child care provider needs to know. 240; 2006.
· EVAC Simulation Slide-based Didactic Video (Appendix C)
Environmental Set-Up and Implementation
The setting is PED resuscitation room or NICU, and the simulation can be conducted in situ or in a simulation lab using either a high-fidelity or low-fidelity manikin. We used a low-fidelity manikin.
Plan to arrive a minimum of one hour prior to the participant and set up the room in "disaster mode" with an infant manikin (high fidelity or low fidelity depending on institutional resources) and the following required items. Rooms can be turned over within five minutes after each participant has successfully evacuated. Please see Table 1 below for a checklist for set up.
With a low fidelity manikin, vital signs may be provided verbally or via a simulator application for a phone or tablet. Physical exam findings can be described concurrently with the learner’s examination of the manikin. The patient is in the process of treatment and the nurse participant is getting a patient sign out. He is a critically ill septic neonate that is endotracheally intubated and thus sedated and minimally responsive. He is receiving antibiotics, IV fluids, and a dopamine infusion (Table 2).
The critically ill neonate should be set up with a low fidelity infant mannikin with initial vital signs and appropriate bedside equipment. An IV pole with medications labeled should be attached to the patient, as well as various other items commonly found in rooms such as gloves, and patient identifying information. For the ED scenario, the participant is told that the patient is awaiting a bed in the NICU. For the NICU scenario, the participant is told that the patient has just been admitted to the NICU and is getting settled. The room should be set up in disarray to mimic a post-earthquake environment with overturned items, drawers opened, phone off the hook, fake cracks in the walls, fake wall or ceiling tile on the floor, leaking water faucet, and other adjustments that you feel would add to the realism of the scenario. Once given instructions to prepare the patient for evacuation after an earthquake, the participant is asked to check themselves, the patient, and the environment for safety, repeat-back instructions for evacuation, and given five minutes to prepare the patient for evacuation. The scenario is completed once the participant begins to hand bag mask ventilate the patient, after five minutes have elapsed, or when the participant has stated that they are ready to evacuate.
Ideally, the scenario should start with the learner outside the room and receive a sign out on the patient. Afterward, as they enter the room, they are informed an earthquake has occurred and they find the room in disarray. The participant notes that they have been unharmed and state that the patient is apparently unharmed from the earthquake. The patient is intubated and remains hooked up to monitors and the ventilator with fluids and medications running. The room is upended with cracks on the wall, a leaky faucet, the telephone off the hook, the trash can overturned, the chair on its side, drawers/cabinets open, and debris on the floor. The participant notes that the room is unsafe. After being informed of the disaster code and need to evacuate the patient within five minutes, the participant repeats back the instructions utilizing a communication tool such as SBAR (Situation, Background, Assessment, Recommendation). The participant expediently prepares the patient for evacuation, and collects necessary items on the patient’s bed, collecting at least all critical items. Once ready to evacuate, the participant disconnects the patient from the ventilator and begins to hand bag mask ventilate the patient. The patient’s vital signs remain static during this scenario. The scenario concludes once the participant begins to hand bag mask ventilate the patient, when they indicate that they are ready to evacuate, or when five minutes have elapsed. If utilizing an embedded participant parent, the parent appears when the scenario has concluded and the participant will update the parent. The scenario progression is detailed in Table 3.
This simulation is targeted toward one learner, and so the first step during or after the scenario is complete is to fill out the critical actions and items checklists. This is included with debriefing materials as we suggest that the facilitator do this with the participant so that the review can occur immediately post sim and can be concurrent with the debrief.
Facilitators may utilize the critical action checklist as below during the scenario to ensure that learners are meeting key action goals and critical items checklist (Figure 1) to ensure that essential items are being collected. These forms are particularly useful during participant debriefing to demonstrate to participants.
Critical action checklist
❏ Visual safety assessment
❏ Participant assesses themself for safety
❏ Participant assesses patient for safety
❏ Participant assesses room for safety
❏ Repeat back
❏ Participant repeats back evacuation instructions utilizing a communication tool such as SBAR
❏ Preparation in five minutes or less
❏ Critical Items (Essential items at least) -see next page for all items
❏ Face mask for bag
❏ Self-inflating bag
❏ Portable oxygen tank
❏ Code medication sheet
❏ Syringes with current medications running on pump
❏ Patient ID tag
❏ Pen or marker
❏ Communication device (e.g. cell phone or hospital mobile phone)
❏ Patient disconnected from ventilator and handbag masked
❏ If utilizing an embedded participant parent, the participant updates the parent at the conclusion of the scenario
Immediately after the learner has completed the simulation, debriefing occurs. Allow approximately 10 minutes for debriefing. The debriefing consists of reviewing the critical items and action checklists, as well as discussing communication and environment safety checking with the participant. The simulation session evaluation form (Appendix B) is used to obtain feedback on the simulation session from the participant. Supplemental educational material is optional, and the provided video slide-based lecture (Appendix C) and EVAC Checklist Card (Appendix D) can be used to help deliver supplemental content regarding evacuation of a critically ill neonate either before or after the simulation. Appendix D does not have to be used but may be helpful as a job aid for participants before, during, or after the simulation. Appendix E can be used as a reference for both facilitators and participants for common healthcare communication tools.
This simulation curriculum is designed as a resource for nursing instructors to review evacuation of a critically ill neonate in the setting of an earthquake. This case is a high-risk, low-frequency scenario that is relevant to nurses caring for critically ill patients who may need to be evacuated in the case of a catastrophic event such as an earthquake. To be successful, learners must be familiar with the steps required at their institution to evacuate such a patient and adequately maintain that patient until help is available to assist.
This simulation case was used at our institution as part of a pediatric nursing disaster curriculum. We used this curriculum over eight days of training spread out over three months, in total with 60 pediatric nurses, 30 of whom were NICU nurses and 30 of whom were ED nurses. Overall, the curriculum received positive feedback from participants. After the first few iterations, based on timeliness and real-time participant feedback, we went over the evacuation items checklist with each participant immediately after the simulation. Most participants preferred going over the checklist together as opposed to filling out the checklist while the participant was filling out the simulation evaluation (Appendix B). While this was more time intensive, participants overall appreciated that they were able to debrief and go over the checklist simultaneously. One respondent suggested having a “cheat sheet” for evacuation, which we have subsequently created (Appendix D) that may be printed on a single page double-sided and downsized to ID card size. In addition, we were unable to capture every participant’s evaluation secondary to the time constraints of participants, although 58% of participants were able to fill out an evaluation. The curriculum received strong positive feedback via the evaluation forms. Learners agreed with statements “The simulation is relevant to my work,” “the facilitator created a safe learning environment,” “the simulation required critical thinking appropriate to my level of experience,” and “the debriefing was effective in identifying areas of improvement” (Table 4). The range of Likert Scores was three in “I was sufficiently oriented to the manikin and equipment before the simulation,” suggesting that some participants felt inadequately oriented to the simulation equipment. In our scenario, it was difficult to orient participants to the manikin prior to the simulation as orienting a participant would have introduced them to the room earlier than the scenario allowed and thus may have affected the simulated evacuation process. If a facility has the resources to have an extra manikin, it might be useful to orient participants to a manikin outside of the simulation room. All but one participant felt that they learned something from the simulation, but that respondent did not specify further in comments. In particular, learners felt that this scenario was useful in prioritizing items for patient evacuation and in differentiating what was essential. Furthermore, learners remarked that they felt better prepared to safely evacuate a critically ill neonate in the setting of a disaster in terms of closed-loop communication, equipment prioritization, patient/self-safety, and efficiency.
Adjustments were made based upon the environment being simulated. For instance, it was useful to add an arterial line to the patient if the setting was the NICU in order to maintain realism, whereas in the ED setting at our institution, arterial lines are rare and including one with an arterial line in the patient was not useful in the ED scenario. This scenario is designed for individual learners to mimic the realism of evacuating their patient alone. Moving forward, it might be worthwhile to have an individual learner prepare two patients for evacuations, as this might occur in an earthquake scenario. A limitation we found was time, as the scenario is designed for one individual, thus it is a significant time investment to run through the curriculum with all of the nurses consecutively. However, we felt that the simulation needed to be designed for one individual in order to maintain realism. In addition, all of the simulations were run in our simulation center (versus in situ in the NICU or the ED), which can make it difficult to suspend disbelief. In spite of these negatives, this scenario is now part of the pediatric disaster simulation series curriculum at our institution as our insitution's leadership is invested in high-yield disaster education as it is located in an earthquake prone zone. We are currently working to create a less time and resource-intensive scenario that may be completed asynchronously such as through virtual simulation to make it more accessible for our nursing workforce. While in-situ simulation is ideal, it is not always feasible secondary to institutional constraints. This scenario did not specifically go over communication with parents, so we suggest that adding in a parent as an embedded participant or asking the participant at the end of the scenario to state how they would communicate with the parent. Table 5 reviews anticipated management mistakes that our learners encountered and suggested ways to mediate them. Additionally, Appendix A contains debriefing materials and techniques.
This simulation is resource-intensive, as it requires extensive environmental preparation in order to meet curricular goals. It may be adjusted for use with less environmental staging for the earthquake, although these changes may compromise the realism of the case. This could be expanded to be a group simulation using a larger number of rooms and manikins to simulate evacuating a full unit.
The implementation of a low-frequency high-impact disaster-related simulation to efficiently evacuate a critically ill neonate and pack critical equipment was well received by bedside nurse learners from the NICU and PED. Implementing the scenario allowed nurse participants to physically practice packing critical equipment, utilize resource management, and practice standardized communication skills. While this scenario may not work for every institution, it can be performed with varying degrees of fidelity and can be expanded to a group simulation model, as well as incorporated as a hands-on aspect of pediatric disaster nursing curriculum, which is typically lecture-based.
- Tsuneishi S, Nakamura H: Struggles of neonatology staff and the network system in the Hanshin‐Awaji earthquake disaster. Pediatr Int. 1995, 37:726-730. https://doi.org/10.1111/j.1442-200X.1995.tb03414.x
- Barkemeyer BM: Practicing neonatology in a blackout: the university hospital NICU in the midst of Hurricane Katrina: caring for children without power or water. Pediatrics. 2006, 117(Supplement 4):S369-S374. 10.1542/peds.2006-0099F
- Ginsberg HG: Sweating it out in a level III regional NICU: disaster preparation and lessons learned at the Ochsner Foundation Hospital. Pediatrics. 2006, 117(Supplement 4):S375-S380. 10.1542/peds.2006-0099G
- Emergency Nurses Association: ENPC: Emergency Nursing Pediatric Course: Provider Manual, 4th edition. Emergency Nurses Association, Des Plaines, IL; 2012.
- Merenstein & Gardner’s Handbook of Neonatal Intensive Care, 8th edition. Gardner SL, Carter BS, Enzman-Hines MI, Hernandez JA (ed): Elsevier, St. Louis, MO; 2015.
- Wong’s Essentials of Pediatric Nursing, 10th edition. Hockenberry MJ, Rodgers CC, Wilson D (ed): Mosby Elsevier, St. Louis, MO; 2016.
- Gray MM, Thomas AA, Burns B, Umoren RA: Identifying crucial equipment and skills needed to evacuate critically ill infants during disasters: using nursing expertise to guide training targets. Prehosp Disaster Med. 2019, 34:370-375. 10.1017/S1049023X19004473
Appendix A: EVAC simulation debriefing materials
This appendix contains a debriefing overview for facilitators to utilize during the simulation and debrief.
This simulation’s debrief allows the learner to go over medical management, hands-on skills, and communication in order to improve patient care.
Debriefing Outline: We suggest that the facilitator goes over the critical action and items checklists immediately after the simulation has completed (see Technical Report).
Facilitator: “This checklist of bedside items was created in conjunction with experienced pediatric nurses. The essential items should be packed for all critically ill patients, while the non-essential items may delay time to evacuation.” It looks like you collected __ number of essential items, __ number of fairly important items, __ number of less important items, and ___ number of non-essential items.”
Facilitator may subsequently review which essential items were missed. If all items were collected, you may prompt, “What helped you remember to collect all of these items?” If essential items were missed, the facilitator may prompt, “What hindered you from collecting this item?”
Appendix B: EVAC simulation session evaluation form
This evaluation form can be given to participants after debriefing to allow for feedback.
What did you learn that will change your future practice?
What could have made this simulation more effective?
Appendix C: EVAC simulation slides-based didactic
This video may be used to supplement learning either prior to or after the simulation.
Appendix D: EVAC simulation participant checklist card
Appendix E: Pediatric disaster simulation communication tools
Common communication terminology used in healthcare and medical simulation settings.
EVAC: Evacuation of Vulnerable and Critical Pediatric Patients for Nurses
Ethics Statement and Conflict of Interest Disclosures
Human subjects: Consent was obtained by all participants in this study. Seattle Children's Institutional Review Board issued approval not applicable. This simulation case was part of a larger study that underwent IRB approval. The larger study was approved by Seattle Children's IRB committee. . Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This simulation was created as part of a larger study looking at Virtual Reality, however, the simulation case was not part of the larger study funds. The larger study received an internal grant from Seattle Children's Hospital, the Academic Enrichment Fund, in the amount of $50,000. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Seattle Children's Simulation Team, Seattle Children's Emergency Department Clinical Research Associates
Cite this article as:
Thomas A, Gray M M, Burns B, et al. (May 26, 2020) EVAC: Evacuation of Vulnerable and Critical Pediatric Patients for Nurses. Cureus 12(5): e8302. doi:10.7759/cureus.8302
Received by Cureus: October 11, 2019
Peer review began: March 05, 2020
Peer review concluded: March 25, 2020
Published: May 26, 2020
© Copyright 2020
Thomas et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.