International Journal of Healthcare Simulation

Background:

During the pandemic, several wards in our surgical wing became re-purposed for COVID patients. This resulted in patients who would usually be nursed in those wards being placed elsewhere. There were also many nurses and medical staff being redeployed to wards in unfamiliar specialities which required caring for patients outside their usual clinical areas. This resulted in some patients with chest drains being nursed outside the usual areas, and incidents being reported regarding their management.

Aims:

The hour-long workshop was designed to simulate the management and understanding of the terminology around chest drains. The hands-on aspect was achieved by modifying a manikin to be able to demonstrate these actions and troubleshoot when things go wrong.

What is meant by a swinging chest drain?

How much bubbling is expected?

Followed by the procedure of inserting a large-bore chest drain using immersive virtual reality

Methods:

Ward nursing staff, operating theatre staff and junior doctors were invited to attend the workshop. Six sessions each with five participants ran over the course of a month. The first part of the workshop was a hands-on session with a modified defunct manikin. We had the locally available kit for people to be able to interact with and understand the mechanics of chest drains Introducing people to the Royal Marsden manual of clinical nursing procedures ^[1] as a reference to be used in parallel with our trust protocols. Hands-on session covered the observations taken for safe management of a chest drain, demonstrating what a swinging and bubbling drain look like. Recognizing when and how to clamp a chest drain was simulated, with a short scenario requiring the attendees to troubleshoot a drain that had stopped swinging and the patient condition deteriorated. How the consumables are changed in the chest drain and its ultimate removal was also covered in the hands-on session as this had been a particular area of concern expressed prior to the workshop. The manikin (Frank) was limited in the ability to insert the chest drain in a realistic manner, so this component of the education was augmented by a virtual reality (VR) option. Pottle ^[2] asserts that VR allows participants to learn from experience as they would do in real life. VR is the use of software to create an immersive simulated environment, to experience VR, participants put on head-mounted display which places them inside an experience, where they can engage with the environment and virtual characters in a way that feels real. VR has a unique power, more than any other simulation technology, to make users believe they are in a different environment. The application used is available on the Oculus go format and is produced by the Royal College of Surgeons in Ireland, it takes the participants through the accident that results in the patient requiring the insertion of a chest drain. They are then faced with decisions regarding his care throughout the experience, following through decisions that may lead to a fatal result for the virtual patient. The VR simulation was in real time, with events unfolding at a realistic pace and included the various airway emergencies unfolding before you after the drain insertion

Results:

Questionnaires were completed before and after the workshop for attendees to evaluate their confidence to independently manage a chest drain. Every attendee reported an increase in confidence because of the session (Table 1).

Table 1:

How confident are you to…….	Pre-session, %	Post-session, %
Monitor vital signs	95	100
Assess chest drain function	60	90
Recognize/monitor swinging drain	60	90
Patient mobilizing with drain	55	90
Recognizing when/why/if to clamp	25	80
Clamp a chest drain	50	80
Wound management post-removal	35	75
Change chest drain bottle	25	65
Remove chest drain	25	55

Implications for practice:

As a result of this session, the ward areas created a ‘chest drain box’ which had everything needed to manage and replace a chest drain included as locating where kit was kept was identified as an issue. This box will be at the side of the patient being managed with the chest drain and will be checked for completeness regularly. This workshop would be useful to repeat because 50% of junior doctors have now rotated placements and many of the ward staff have been re-deployed to other areas.