TRADE OFF Staff members should be able to handle multiple roles, since you never know who'll be present during an actual MH emergency.

As a consultant for the Malignant Hyperthermia Association of the United States (MHAUS) for more than 10 years, I've seen MH simulations done in many different ways. To make sure your drills keep you as prepared as possible, keep these key factors in mind.

1. Have an anesthetist lead the simulation. When a nurse or someone else leads, you don't always get buy-in from everyone, and responding to an MH crisis is a team sport. You want everyone to participate. Moreover, anesthesia providers have more training and a better understanding of the clinical components, since MH is caused by an anesthetic (either succinylcholine or an inhalation agent).

2. Recognize and react. Focus training on learning to recognize MH symptoms and on treating it as quickly as possible. It's well-documented that if dantrolene is given within the first 10 minutes after symptoms develop, outcomes are much better.

3. Get everyone involved. The best simulations are when the leader continually assigns roles to the participants. The people being assigned are participating, and the others know they might be assigned a role at any point, so they're also fully engaged and focused.

4. Put roles in writing. Write roles out on cards and have the team leader hand them out as people come into the room. People should be able to read and perform their roles without consulting the team leader.

5. Make sure staff can handle multiple roles. This is especially important in a surgery center, where manpower is likely to be an issue. The danger of assigning each person only one role is that when an actual MH crisis occurs, that person may not be in the facility.

6. Focus on the logistics. Stress more on what you need and where it's located than on physically treating the patient. In an MH crisis, the hands-on portion with the patient shouldn't be the focus. The focus should be on knowing where the MH cart is and bringing it into the room, getting ice, reconstituting dantrolene and calling the MHAUS hotline.

TALK ISN'T CHEAP
Post-MH Drill Discussions Help Fill Important Gaps

ROOM TO THINK Having a manageable number of people in the OR during an MH drill promotes learning.

One of the critical elements when you're conducting malignant hyperthermia simulations is the debriefing that follows each drill. We've found that that's where a lot of the learning takes place. And every time we do it, we learn something new. So we always make it a point to talk to the staff afterward. What did we learn? What went well? What can we improve on? Did everyone clearly understand what their roles were?

The feedback is always valuable. For example, we learned over time that when we packed our entire staff into the OR for a simulation, it wasn't as conducive to learning as we wanted it to be. We simply weren't going to get the full benefit of the simulation with 30 people in the room. So now when we do simulations, we split the staff and do half on Wednesdays and the other half on Fridays.

At another of our debriefings, people said it wasn't always 100% clear whom the person running the drill was talking to. To improve communication we began making it a point to use first names: Lynn, I need you to go get this. Sarah, I need you to call the MH line. And so on. And the person being called on acknowledges the instruction, as well: Yes, I'll do that.

Sometimes the things you take for granted turn out to be challenges. Like ice. We knew from Malignant Hyperthermia Association of the United States protocol that we'd need to apply ice to the patient in a real MH emergency. We could bring in a bucket of ice, but we had nothing to put the ice in. Somebody was having to run to get bags every time. Now we've added clear plastic bags to our MH cart.

We also realized that our ice machine was too slow. Do you know how slowly that ice machine gives ice, people were saying. The solution: In an emergency, we take the top off and fill the bucket instead of using the dispenser. That may sound obvious or intuitive, but it's not the kind of riddle you want to be having to solve when someone's life is on the line. Having regular drills and post-drill discussions can help you address all the issues that might arise, and do so before it's a real emergency.

— Lynn Gettrust, MSN, RN, ACNS-BC

Ms. Gettrust ([email protected]) is a perioperative clinical nurse specialist at the Department of Veterans Affairs in Waukesha, Wis. This article reflects her views alone and does not necessarily reflect the views or policies of the Department of Veteran Affairs or the United States Government.

SPELLED OUT Pre-printed cards let participants read and perform their roles without having to wait for instructions.

7. Reconstituting dantrolene is a chore. You don't need to reconstitute more than 1 or 2 vials of dantrolene during a drill. Just make sure people understand how much effort is involved in reconstituting each vial. Then you can say: And for this patient, we'd need to reconstitute 15 vials. There's a wow factor when people realize how laborious the process is.

8. Have a transport plan in place. Make post-stabilization transport plans part of the simulation. It's crucial that every surgery center have a transport plan in place before an MH episode happens, and that everyone knows the transport plan. Depending on how far away you are from the receiving facility, I recommend that the anesthesia provider accompany the patient in the ambulance along with a sufficient amount of dantrolene. He should be able to give reports to the receiving facility en route and continue to administer dantrolene, if needed.

9. Keep track of who's trained and who isn't. The Joint Commission recommends that you do simulations once a year. But if turnover is high or you have a lot of new people coming into your facility, keep it in mind and consider increasing the frequency of your drills to get new staff up to speed.

10. Rotate between scheduled drills and unscheduled ones. If your purpose is to educate, then you want drills to be scheduled. If your purpose is to assess readiness, you want them to be a surprise. I think it's a great idea to rotate between scheduled and unscheduled drills, and to have one of each every year. That will obviously be more time-consuming than one drill a year, but it will also be more effective.

11. Have contingency plans. Keep in mind that the people you train might not be the people who are there if an episode happens in the middle of the night. Those are things that need to be discussed and planned for. Whom are you going to call or page? Are you going to bring people in from home or not? Contingency plans should be part of the simulation. OSM