Program Description
Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.
This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.
Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.
After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.
Objectives
The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).