AHRQ Safety Program for Perinatal Care

Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Purpose of the tool: The Preeclampsia/Seizure In Situ Simulation tool provides a

sample scenario for labor and delivery (L&D) staff to practice teamwork,
communication, and technical skills in the unit where they work. Upon completion of the
Preeclampsia/Seizure In Situ Simulation, participants will be able to do the following:

 Demonstrate effective communication with the patient and support person during
a labor complicated by preeclampsia and seizure.

 Demonstrate effective teamwork and communication with clinical team members

during assessment of the patient, changes in the patient’s clinical status, and
actions required for the optimum patient outcome.

 Demonstrate timely and accurate clinical assessment and intervention for

preeclampsia with seizure.

 Demonstrate the efficient use of checklists, protocols, or similar cognitive aids for
evaluation and treatment of preeclampsia and seizure.

Who should use this tool: Simulation facilitators

How to use this tool: This tool should be used in connection with the “Facilitation
Instructions for Conducting In Situ Simulations” to prepare, conduct, assess, and debrief
in situ simulations on L&D units. Simulation facilitators can adapt, modify, and further
tailor this sample scenario to meet the training needs of their unit staff or resources
available in their facility.
Other resources: Additional resources related to preeclampsia are available at the
following Web sites:

 California Maternal Quality Care Collaborative: [Link]

tool-kits/toolkits/preeclampsia-toolkit

 American Congress of Obstetricians and Gynecologists District II. Safe

Motherhood Initiative. Severe Hypertension Bundle: [Link]
ACOG/ACOG-Districts/District-II/SMI-Severe-Hypertension

Note: The information presented in this document does not necessarily represent the views of
AHRQ. Therefore, no statement in this document should be construed as an official position of AHRQ or
of the U.S. Department of Health and Human Services. Outside resources identified do not represent an
endorsement of those resources and do not reflect the position of AHRQ or the Federal Government.
 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Sample Scenario for Preeclampsia and Seizure In Situ Simulation

This document provides a sample scenario for an in situ simulation for a labor
complicated by preeclampsia and seizure. This document contains the following:
 Preparation Required
 Clinical Context, Distractors, Triggers, and Expected Behaviors for the Simulation
Facilitator
 Preeclampsia and Seizure Simulation Assessment Tool
 Clinical Context, Triggers, and Distractors Formatted for Printing Separately

Refer to the document titled “Facilitation Instructions for Conducting In Situ Simulation”
for general guidance and instructions regarding presimulation planning, presimulation
briefing, simulation assessment, and simulation debriefing.

During the simulation, participants are encouraged to practice the use of protocols,
checklists, or cognitive aids the unit has developed or adapted for use in evaluating and
treating preeclampsia and seizure.

Preparation Required
This simulation requires people to play the roles of the patient and the patient’s support
person:
 The actor playing the patient should wear a patient gown, padding (to simulate a
postpartum belly), and a wrist identification band and should lie in bed. The
simulated patient (“actor”) should wear scrubs under the gown to ensure her
privacy.
 The actor playing the support person should be briefed on his or her disposition
and how to interact with others in the simulation.

In addition, the following props (i.e., simulated equipment and materials) are required:
 Simulated intravenous (IV) fluids and medications (e.g., magnesium sulfate,
calcium gluconate). The team should order and access simulated fluids and
medication the way it normally would order these items—for example, through
electronic order entry, a Pyxis machine, or a rapid response kit or cart. This
allows the team to experience the normal passage of time required to order and
access necessary supplies for treatment. Prior planning and coordination with the
pharmacy for these simulated items will help make the simulation as realistic as
possible.
 Fetal heart rate (FHR) simulator or FHR strips for teams to assess. Simulator
should be capable of simulating a Category I and II tracing. If a simulator is not
available, old FHR paper strips can be used.
 Simulated urine in a Foley catheter bag (yellow food coloring can be used to
make urine darker).
 Lab result printouts or a simulated patient in the electronic medical record with
the necessary lab results for the simulation.
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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Clinical Context, Triggers, Distractors, and Expected Behaviors for the Simulation
The content of this simulation is divided into four parts: Clinical Context, Triggers,
Distractors, and Expected Behaviors. The Clinical Context is provided at the beginning
of the simulation in the form of a patient handoff and introduces that simulated patient
and her clinical history. The handoff is followed by a series of Triggers and Distractors,
events or actions that introduce new information and shape the context of the clinical
response. The simulation facilitator introduces the Triggers and Distractors throughout
the course of the simulation. A set of Expected Behaviors is also provided for the
Clinical Context and each set of Triggers and Distractors. The Expected Behaviors offer
a list of ideal actions that the clinical team might take in response to each set of events
in the simulation with particular regard to those that foster effective teamwork and
communication. The Expected Behaviors can also serve as a tool to use in evaluating
the performance of the simulation participants.

Clinical Context
The facilitator provides the clinical context to person in the role of nurse. This can be
done using a verbal report and handoff from one nurse to another nurse during change
of shift.
“Emilia Harper is a 20-year-old G1P0 at 34 weeks and 1day gestational age admitted 2
hours ago with abdominal pain. Her prenatal history is unremarkable except for
heartburn since the first trimester. She’s been unable to distinguish between epigastric
pain or contractions. She denies a headache. I just checked her cervix and she is 1
cm/long. She’s contracting every 3-4 minutes.
“Her admitting blood pressure was 150/100, but she’s rested and they’ve come down.
Pulse 88, temp 98.6, resp rate16, FHR 145, Category I. Her Hgb [hemoglobin] on
admission was 11.8. She dipped 2+ protein in her urine, and she has a Foley catheter
since she couldn’t go on her own.
“Dr. Smithson is concerned about preeclampsia and has ordered some labs, which
haven’t come back. She wanted to assess her for 2 hours, so she should call any
minute. Her IV is running at 125 ml/hour 0.5 normal saline.”
This information may be withheld unless asked for:
“I’m not sure why, but the lab said they are really busy right now and they should be
back any minute. Labs ordered were ALT [alanine aminotransferase], AST [aspartate
aminotransferase], platelets, uric acid, BUN [blood urea nitrogen] and creatinine.”

Expected behavior/performance (not in any particular order):

 Nurse introduces self to the patient and begins assessment.

 Nurse asks about status of labs.

 Nurse plans to call doctor.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger #1
Patient volunteers information to assessing nurse:
“You know, the other nurse asked me if I had a headache, and I didn’t at first, but I do
have one now.”
“My headache is really bothering me. Can I get some medicine?”

Clinical information provided on cards (one at a time) in response to assessment

actions taken by team. For example, after team measures blood pressure (BP),
the BP value is provided to team on a card.
Pulse 90
BP 140/90
Temp 37.2
O2 Saturation 98% on room air
FHR 145 Category I with variability and no decelerations
Deep tendon reflexes (DTRs) 3+, no clonus

The facilitator may provide answers to team as needed to help maintain the flow of the
simulation.

Distractors
Patient: “I’m really hungry. Can I get something to eat?”
Partner mentions that the other nurse mentioned something about preeclampsia.
Partner wants to understand preeclampsia: “Why does it happen? She doesn’t seem
very sick.”
Partner receives many cell phone calls.

Expected behavior/performance:
 Nurse reassures patient and partner.

 Nurse reassesses maternal and fetal status.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger #2
Lab staff member calls patient’s nurse with a critical test result:
 Platelets 98,000 [critical test result]
 AST 44
 ALT 56
 BUN, creatinine, and uric acid not back

Clinical information provided on cards (one at a time) in response to assessment

actions taken by team. For example, after team measures BP, the BP value is
provided to team on a card.
Pulse 100
BP 160/102
Temp 37.2
FHR 145 Category I
DTRs 3+, no clonus
Patient with right-sided epigastric tenderness.

The facilitator may provide answers to team as needed to help maintain the flow of the
simulation. Elevated blood pressure, headache, and epigastric pain should continue
while the team attempts various measures to address.

Distractors
Patient holds top of abdomen and moans in pain.
Partner doesn’t understand what’s going on. “Is she in labor?”
Partner updates family by phone.

Expected behavior/performance (not in any particular order):

 Nurse calls for additional help, provider, or rapid response.
 Situation-Background-Assessment-Recommendation (SBAR) is used to inform
others of the situation when they arrive. Additional help might be attending
physician, anesthesiology, nursing, or rapid response team.
 All team members call out critical patient information.
 Provider speaks to patient and support person or delegates to another team
member to inform and answer questions.
 All team members use closed-loop communication and provide mutual support to
one another.
 Leader may call team huddle.
 Team initiates appropriate clinical response per any protocols, checklists, or
cognitive aids.
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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger #3
Patient starts to have a tonic/clonic seizure.

Clinical information provided on cards (one at a time) in response to assessment

actions taken by team. For example, after team measures BP, the BP value is
provided to team on a card.
Pulse 60
BP 170/105
Temp 37.2
O2 Saturation 93% on room air
FHR 120 Category II with minimal variability and variable decelerations to 70.
Generalized tonic/clonic seizure activity.

The facilitator may provide answers to the team as needed to help maintain the flow of
the simulation. This may include providing interval maternal and fetal assessments in
response to team actions. This may vary to include various FHR patterns, and maternal
physical assessments. The facilitator allows the patient to continue to seize while the
team attempts various measures to address.

Distractors
Partner is overwhelmed and feels faint. “I think I’m going to throw up.”

Expected behavior/performance (not in any particular order):

 Provider calls for additional help or a rapid response.

 Situation-Background-Assessment-Recommendation (SBAR) is used to inform

others of the situation when they arrive. Additional help might be attending
physician, anesthesiology, nursing, or rapid response team.

 All team members call out critical patient information.

 Provider clearly demonstrates leadership role.

 Provider speaks to support person or delegates to another team member to

inform and answer questions.

 Team initiates appropriate clinical response per any protocols, checklists, or

cognitive aids.

 Leader may call team huddle.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

 All team members use closed-loop communication and provide mutual support to
one another.

Trigger #4
When appropriate during the unfolding scenario (after team has huddled, additional help
has arrived, and next steps in patient management are decided):
Tonic-clonic seizure activity stops.

Clinical information provided on cards (one at a time) in response to assessment

actions taken by team. For example, after team measures BP, the BP value is
provided to team on a card.
Pulse 60
BP 135/90
Temp 37.2
O2 Saturation 93% on room air
FHR 110 Category II with minimal variability and intermittent late decelerations.
DTRs 3+, no clonus

The facilitator may provide answers to team as needed to help maintain the flow of the
simulation. This may include providing interval maternal and fetal assessments in
response to team actions. This may vary to include various FHR patterns, maternal
physical assessments, etc.
Facilitator ends the simulation after no further opportunities for teamwork and
communication are apparent.

Expected behavior/performance (not in any particular order):

 SBAR is used to inform others of the situation when they arrive. Additional help
might be attending physician, anesthesiology, nursing, or rapid response team.

 All team members use closed-loop communication and provide mutual support to
one another.

 Leader calls a team huddle to establish a plan of care based on fetal and
maternal clinical assessments.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Sample Scenario Preeclampsia and Seizure In Situ Simulation Assessment Tool

(Optional)

This tool provides a list of expected behaviors in response to the Clinical Context and
each set of Triggers and Distractors in the simulation and can be used as a tool in
evaluating the performance of the simulation participants.

Trigger 1: Patient Headache

Targeted Behavioral Response Observed Not Observed Notes

Nurse reassures patient and

partner.

Nurse reassesses maternal and

fetal status

Trigger 2: Critical Lab Results

Targeted Behavioral Response Observed Not Observed Notes

Nurse calls for additional help,

provider, or rapid response.

SBAR is used to inform others of

the situation when they arrive.

All team members call out critical

patient information.

Provider speaks to patient and

support person or delegates to
another team member to inform
and answer questions.

All team members use closed-

loop communication and provide
mutual support to one another.

Leader may call team huddle or

continue to direct care.

Team initiates appropriate

clinical response per any
protocols, checklists, or cognitive
aids.

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AHRQ Safety Program for Perinatal Care Preeclampsia/Seizure 8
 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger 3: Patient Seizes

Targeted Behavioral Response Observed Not Observed Notes

Provider calls for additional help

or a rapid response.

SBAR is used to inform others of

the situation when they arrive.

All team members call out critical

patient information.

Provider clearly demonstrates

leadership role.

Provider speaks to support

person or delegates to another
team member to inform and
answer questions.

Team initiates appropriate

clinical response per any
protocols, checklists, or cognitive
aids.

Leader may call team huddle.

All team members use closed-

loop communication and provide
mutual support to one another.

Trigger 4: Creating a Plan

Targeted Behavioral Response Observed Not Observed Notes

SBAR is used to inform others of

the situation when they arrive.

All team members use closed-

loop communication and provide
mutual support to one another.

Leader calls a team huddle to

establish a plan of care based on
fetal and maternal clinical
assessments.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Clinical Context, Triggers, and Distractors Formatted for Printing Separately

The Clinical Context, Triggers, and Distractors used in this simulation scenario are
provided on the next several pages in a format suitable for printing on cardstock in
preparation for facilitating this in situ simulation using printed cards. The printed cards
can be handed to the simulated patient or participating staff members at appropriate
intervals during the simulation.

Clinical Context
“Emilia Harper is a 20-year-old G1P0 at 34 weeks and 1 day gestational age admitted
2 hours ago with abdominal pain. Her prenatal history is unremarkable except for
heartburn since the first trimester. She’s been unable to distinguish between
epigastric pain or contractions. She denies a headache. I just checked her cervix and
she is 1 cm/long. She’s contracting every 3-4 minutes.

"Her admitting blood pressure was 150/100, but she’s rested and they’ve come down.
Pulse 88, temp 98.6, resp rate16, FHR [fetal heart rate] 145, Category I. Her Hgb
[hemoglobin] on admission was 11.8. She dipped 2+ protein in her urine and she has
a Foley catheter since she couldn’t go on her own.

"Dr. Smithson is concerned about preeclampsia and has ordered some labs, which
haven’t come back. She wanted to assess her for 2 hours, so she should call any
minute. Her IV [intravenous line] is running at 125 ml/hour 0.5 normal saline.”

Additional Narrative [if needed]:

“I’m not sure why, but the lab said they are really busy right now and they should be
back any minute. Labs ordered were ALT [alanine aminotransferase], AST [aspartate
aminotransferase], platelets, uric acid, BUN [blood urea nitrogen] and creatinine.”

\ Sample Scenario
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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger #1

Patient: “You know, the other nurse asked me if I had a headache, and I
didn’t at first, but I do have one now.”

Patient further shares the following complaints:

“My headache is really bothering me. Can I get some medicine?”

Clinical information to be provided to team in response to their

assessment after trigger #1

Pulse 90

BP [blood pressure] 140/90

Temp 37.2

O2 Saturation 98% on room air

FHR 145 Category I with variability and no decelerations

DTRs 3+, no clonus.

\ Sample Scenario
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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Distractors (Trigger #1)

 Patient: “I’m really hungry. Can I get something to eat?”

 Partner mentions that the other nurse mentioned something about

preeclampsia. Partner wants to understand preeclampsia.

“Why does it happen? She doesn’t seem very sick.”

 Partner receives many cell phone calls.

Trigger #2

Lab staff call patient’s nurse with a critical test result:

 Platelets 98,000

 AST 44

 ALT 56

 BUN, creatinine, and uric acid not back

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Clinical information to be provided to team in response to their

assessment after trigger #2

Pulse 100

BP 160/102

Temp 37.2

FHR 145 Category I

DTRs [deep tendon reflexes] 3+, no clonus

Patient with right-sided epigastric tenderness.

Distractors (Trigger #2)

 Patient holds top of abdomen and moans in pain.

 Partner doesn’t understand what’s going on. “Is she in labor?”

 Partner updates family by phone.

\ Sample Scenario
AHRQ Safety Program for Perinatal Care Preeclampsia/Seizure 13
 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Trigger #3

Patient starts to have a tonic/clonic seizure.

Clinical information to be provided to team in response to their

assessment after trigger #3

Pulse 60

BP 170/105

Temp 37.2

O2 Saturation 93% on room air

FHR 120 Category II with minimal variability and variable decelerations to

70.

Generalized tonic/clonic seizure activity.

\ Sample Scenario
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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Distractors (Trigger #3)

 Partner is overwhelmed and feels faint.

“I think I’m going to throw up.”

Trigger #4

Tonic-clonic seizure activity stops.

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 Sample Scenario for Preeclampsia/Seizure In Situ Simulation

Clinical information to be provided to team in response to their

assessment after trigger #4

Pulse 60

BP 135/90

Temp 37.2

O2 Saturation 93% on room air

FHR 110 Category II with minimal variability and intermittent late

decelerations.

DTRs 3+, no clonus

AHRQ Publication No. 17-0003-22-EF

May 2017

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