In‑Situ Simulation Scenario Pack: Deteriorating Patient

Overview

This scenario pack is designed to run brief, realistic in‑situ simulations that train frontline teams to recognize and manage a deteriorating patient while surfacing latent system vulnerabilities. Use the materials in real clinical areas with the actual team, equipment, and workflows to reveal environmental, equipment, communication, and process gaps.

Primary Hunger

Educators want simulations that both build team skills and reliably identify system-level risks so improvement work can follow.

Learning Objectives

• Recognize early signs of clinical deterioration and initiate appropriate escalation.
• Practice interprofessional communication (SBAR, closed-loop) during an urgent event.
• Demonstrate role clarity and task allocation under time pressure.
• Identify system failures (equipment access, documentation, pathway ambiguity) that impede timely care.
• Debrief to capture actionable system improvement opportunities.

Target Participants & Roles

Recommended team: bedside nurse, charge nurse or team leader, resident or attending clinician, respiratory therapist (if applicable), patient-care assistant. Observer roles: 1–2 systems observers (use the observation checklist below).

Role Cards (short)

• Bedside nurse: Primary assessor and communicator to the team; start monitoring and basic interventions.
• Team leader (physician or senior nurse): Make decisions, call for escalation, assign tasks.
• Respiratory therapist: Manage airway and oxygen therapy.
• Patient-care assistant: Assist with positioning, IV access support, and equipment fetch.
• Observers: Use the observation checklist and focus on systems, workflow, and human factors.

Scenario Summary (Short)

Adult inpatient developing sepsis with progressive hypotension and altered mental status over 10–15 minutes. Team must identify deterioration, call for help using local escalation pathway, initiate resuscitation steps, and request required equipment/medications. The scenario is intentionally seeded with a systems issue (e.g., missing emergency antibiotic kit, delayed crash‑cart access, unclear escalation phone number) that observers should notice and record.

Detailed Scenario Script

1. Baseline: Patient post-op day 2, mild tachycardia. Vitals recorded on whiteboard. Nurse finishes med pass.
2. After 2 minutes: Nurse notes increased HR and RR, small drop in BP. Patient becomes mildly confused.
3. Prompt: If team monitors closely, they will escalate via the ward rapid-response pathway. Otherwise, deterioration continues.
4. Seeding system issues: Emergency antibiotic kit is located in a locked cabinet requiring access code (delays), or the unit’s escalation phone is overloaded (calls fail), or documentation for sepsis protocol is ambiguous.
5. Expected endpoints: Team calls RRT or follows local escalation, starts IV fluids, orders and administers antibiotics once available, and organizes monitoring. Scenario ends when team either stabilizes the patient or declares need for higher-level care—use this to drive debrief topics.

Setup & Equipment Checklist

• Manikin or standardized patient able to display altered mental status (or scripted actor).
• Monitor with adjustable vitals (or laminated vital signs script).
• IV supplies, fluids, syringes, oxygen delivery options.
• Access to actual unit equipment: crash cart location, emergency medication kit (seeded to create a delay), escalation phone numbers, sepsis pathway documentation.
• Stopwatch or timing device, clipboard with scripts for confederates, name badges for roles, and spare PPE if relevant.

Observation Checklist (for systems-focused observers)

Observers should note both behaviors and system factors. Use concrete, timed observations rather than judgments.

• Recognition & Decision-Making: Time from vital change noted to escalation call; who recognized deterioration?
• Communication: Use of SBAR or closed-loop; clarity of orders; documentation gaps.
• Role & Task Allocation: Were tasks delegated? Any duplication or missed tasks?
• Equipment & Supply Access: Where was necessary equipment located? Any delays caused by location, locks, inventory?
• Escalation Pathway: Was the correct number used? Were there barriers (busy lines, unclear steps)?
• Environment & Workflow: Physical layout issues, competing priorities, interruptions, or noisy conditions that affected care.
• Documentation & Handoffs: Was critical information captured? Did EHR or paper workflows slow actions?
• Psychological Safety & Team Climate: Who spoke up? Any signs of reluctance or blame during the event?

Debrief Guide & Prompts

Use a structured debrief (e.g., reaction → analysis → summary). Aim to surface both human performance and system issues, and convert observations into specific improvement ideas.

Starter Prompts

• How did that feel? What went well in the team’s response?
• What were the key decisions and how were they made?
• Were there any surprises or unexpected barriers?
• Which system issues affected patient care or timeliness (equipment access, escalation phone, unclear protocol)?
• If you were to design one small change to make the next event easier, what would it be?

After discussion, capture 2–3 concrete action items: who will take them, what exactly will change, and how success will be measured.

Psychological Safety Checklist for Facilitators

• Set a supportive tone before the simulation: this is a learning event, not an assessment of individuals.
• Explain that systems issues are expected and the purpose is to learn and improve the environment.
• Use advocacy-inquiry language: state an observation, then ask to understand reasoning.
• Avoid early judgment; invite multiple perspectives during debrief.
• Protect confidentiality of team members and avoid punitive follow-up from the simulation unless there is an immediate safety concern requiring escalation.

Timing & Logistics

Scenario length: 10–15 minutes. Debrief: 20–30 minutes. Run 1–2 scenarios per shift to minimize disruption. Coordinate with unit leadership, bed flow, and patient privacy requirements. Ensure informed consent and safety for any real patients or family presence in the area.

Evaluation & Success Criteria

• Team recognizes deterioration and follows escalation pathway within target timeframe (define locally).
• Observers identify at least one actionable system gap during the debrief.
• Team generates at least one concrete improvement idea with an owner and timeline.

Common Pitfalls & Tips

• Don't over-direct participants; allow natural team responses so system issues surface.
• Seed only one or two system issues per scenario to keep debrief focused.
• Rotate observer roles so clinicians can participate in scenarios frequently.

Adaptations

Adjust severity, patient type, or seeding to target specific risks (e.g., pediatric deterioration, delayed recognition in dementia, language-barrier scenarios). Consider multi-unit simulations to test inter-departmental escalation pathways.

Attachments / Ready-to-Print

Include: full script slips for confederates, printable role cards, a one-page observation checklist, and a debrief template to capture action items. Store these as quick-reference PDFs for facilitators.

References & Further Reading

Links to local escalation policy, sepsis pathway, human factors in healthcare simulation, and psychological safety resources. (Add site-specific documents when tailoring.)