Each of the scenarios were run 16 times. Staff who took part in each scenario routinely worked on the head and neck ward and were familiar with the current catastrophic haemorrhage protocols at NHS Ayrshire and Arran. The mean drug to patient time for intravenous administration in scenario 1 (current protocol) was 124 s with a range of 78–202 s. In scenario 2 (grab-bag protocol) the mean time for intravenous administration was reduced to 48 s. The range also reduced and narrowed to 33–53 s. The mean time to attend the patient in scenario 1 was 115 s compared with 42 s in scenario 2. Both the time to attend the patient and the intravenous administration time were shown to be statistically significant using the Wilcoxon ranked test, with p values of less than 0.01.
The variability in time noted in scenario one can at least in part be attributed to how nursing staff interacted with the controlled drug book. As investigators we did not specifically state in either scenario that controlled drugs were accounted for or not in the controlled drug book. In scenario 1, some of the longer scenarios occurred where the nursing staff opted to sign the controlled drug book prior to the administration of intravenous drug. Shorter scenarios occurred when the nursing staff opted to bring the controlled drug book to the patient. However, in scenario 2, all participants stated that as the drugs were placed in a separate storage area to the standard vials that something would be written in the controlled drug book to account for this, even though this was not explicitly stated to the participants.
Lessons and limitations
Catastrophic haemorrhage from head and neck malignancy is a commonly fatal complication and is distressing for patients, families/carers and nursing and medical staff. Previous guidelines focus on non-pharmacological measures primarily. The administration of sedative medication is now widely recommended in the literature with primary aim of alleviating the distress of the patient. There is some variation as to exact medications recommended and the route, but the most common is midazolam and second most common is an opioid such as morphine or diamorphine. While these medications are often prescribed for patients deemed at risk of carotid blowout, the time taken to prepare the medications combined with rate of bleeding and overall frailty of a terminal head and neck cancer patient means these medications are often not administered in time. The evidence we have for this is anecdotal as it is a difficult area to study.
Due to the unpredictability of a carotid blowout event coupled with the rapid decline of the patient, nursing staff are often the first responders to a catastrophic haemorrhage in secondary care, and may be the sole caregivers depending on how rapidly the patient declines prior to death. Nursing staff also therefore report feelings of helplessness and anxiety when managing a catastrophic haemorrhage. Similar negative feelings are reported within the literature with respect to interviews with family. These include: feared, traumatic, horrific and dreaded. A review of terminal haemorrhage also clearly states that the ‘imminence of death’ causes ‘overwhelming distress’ to patients.3
Scottish palliative care guidelines focus on non-pharmacological methods in the management of carotid blowout including: not leaving the patient, the use of dark coloured towels to cover blood loss, staying calm and not shouting for help. Pharmacological methods are only currently recommended if time allows and if a second staff member can prepare the medications so as not to leave the patient.10 From our simulation, where the average time to administration is over 2 min and was as long as 3 min and 20 s, the current guidance would appear sensible as one would expect a patient to derive reduced benefit from the medication following this delay. However, by implementing a fairly simple alteration in practice with a grab-bag, these times can be reliably reduced to under a minute. We feel that this means that pharmacological therapies could be given further credence in the management protocol, without compromising non-pharmacological methods. This also provides nursing colleagues with another strategy in the management of a major haemorrhage.4 11–14 As a group would advocate a single grab-bag be prepared once a patient on the head and neck ward be identified by a senior clinician as being at risk of catastrophic haemorrhage. The contents is prescribed to the at risk individual only and would only be replaced if the medications expired or the syringe was noted to be damaged. It had been proposed that the drugs could be kept in patient’s individual rooms; however, this raises some safety concerns regarding controlled drugs being left unmonitored. We feel our current approach represents a compromise between efficient pharmacological treatment and patient safety.
However, it should be noted that the overall efficacy of both pharmacological and non-pharmacological management of terminal haemorrhage is based on low level evidence. Two recent systematic reviews both noted that the majority of all management recommendations with respect to terminal haemorrhage arises from level 5 evidence (expert opinion). Both studies also note the need for further high-level research into the area, although this may be extremely challenging due to ethics and emotion regarding the event and the practical ability to recruit a large enough patient cohort.4 9
The aforementioned variance in timings with respect to the controlled drugs book was an interesting and unexpected finding. Prior to the simulation, there was no explicit instructions regarding the controlled drugs book. Participants were informed to behave as they would in a real emergency scenario but to assume that correct doses of medication were prescribed and the dummy vials represented that correct dose. Participants stated that as the syringe was already drawn up, they assumed that doses would already be accounted for within the controlled drug book even though this was not explicitly stated. The variable responses with respect to this aspect of the simulation demonstrates the need for an explicit statement about how nursing colleagues should document the administration of a controlled drug in a time dependent emergency.
As carotid blowout is a rare event, simulation modelling was deemed to be the best method to assess team performance. Simulation also allowed for a predesigned clinical episode, as waiting for multiple actual clinical episodes would not have been possible. However, the efficacy simulation studies have only been studied with observational studies although with largely positive results. There has yet to be validation with experimental studies. Also, some observational studies have noted that repeated simulation can promote abnormal learning, for example, if the scenario was run too many times in one shift the nurses may run straight to the drugs cupboard on hearing the emergency buzzer rather than to the patient room. Simulation studies also rely on a rigid protocol to ensure reliability but as a result this makes simulation less flexible and adaptable than a more common quality improvement methodology such as a plan, do, study, act (PDSA) model.15–17