INTRODUCTIONSimulation-based medical education (SBME) improves medical knowledge compared with no intervention. In traditional SBME, more time is spent debriefing than practicing skills. Rapid cycle ...deliberate practice (RCDP) simulation allows learners to practice skills repetitively, receive brief interspersed feedback, and has been shown to improve individual performance of resuscitation skills in simulation; it has not been compared with traditional simulation methods.
OBJECTIVEThe aim of the study was to compare traditional and RCDP SBME.
METHODSFour pediatric resuscitation cases (3 for teaching and 1 for testing) were developed. For the RCDP arm, traditional cases were deconstructed into sequences of progressively difficult rounds. The last RCDP round served as the traditional arm scenario.Learners received 1 type of instruction on 2 separate days. Pretest and posttest performance during simulation were video recorded and scored using the Simulation Team Assessment Tool; satisfaction surveys were collected.
RESULTSPretest team performance was similar in both groups. Simulation Team Assessment Tool score improvement for RCDP was 7.2% (95% confidence interval, 3.4% to 11%) and traditional was 0.8% (95% confidence interval, −11% to 13%). The difference in improvement of the human factors subscore was statistically significant; RCDP improved 10.2% and traditional improved 1.7% (P = 0.013). The RCDP technique was well received by learners but caused fatigue.
CONCLUSIONSThis pilot study showed a trend toward greater improvement in team performance and significantly greater improvement for human factors with RCDP compared with traditional simulation. Future studies comparing RCDP with other methods are needed to identify best practices and applications of RCDP, including which learners and learning objectives are best suited to RCDP.
Abstract
Background
Healthcare workers faced unique challenges during the early months of the COVID-19 pandemic which necessitated rapid adaptation. Clinical event debriefings (CEDs) are one tool ...that teams can use to reflect after events and identify opportunities for improving their performance and their processes. There are few reports of how teams have used CEDs in the COVID-19 pandemic. Our aim is to explore the issues discussed during COVID-19 CEDs and propose a framework model for qualitatively analyzing CEDs.
Methods
This was a descriptive, qualitative study of a hospital-wide CED program at a quaternary children’s hospital between March and July 2020. CEDs were in-person, team-led, voluntary, scripted sessions using the Debriefing in Suspected COVID-19 to Encourage Reflection and Team Learning (DISCOVER-TooL). Debriefing content was qualitatively analyzed using constant comparative coding with an integrated deductive and inductive approach. A novel conceptual framework was proposed for understanding how debriefing content can be employed at various levels in a health system for learning and improvement.
Results
Thirty-one debriefings were performed and analyzed. Debriefings had a median of 7 debriefing participants, lasted a median of 10 min, and were associated with multiple systems-based process improvements. Fourteen themes and 25 subthemes were identified and categorized into a novel Input-Mediator-Output-Input Debriefing (IMOID) model. The most common themes included communication, coordination, situational awareness, team member roles, and clinical standards.
Conclusions
Teams identified diverse issues in their debriefing discussions related to areas of high performance and opportunities for improvement in their care of COVID-19 patients. This model may help healthcare systems to understand how CED tools can be used to accelerate organizational learning to promote safety and improve outcomes in changing clinical environments.
In 2012, Botswana embarked on an organized public approach to prehospital medicine. One goal of the Ministry of Health (MOH) was to improve provider education regarding patient stabilization and ...resuscitation. Simulation-based instruction is an effective educational strategy particularly for high-risk, low-frequency events. In collaboration with partners in the United States, the team created a short, simulation-based course to teach and update prehospital providers on common field responses in this resource-limited setting. The objective of this study was to evaluate an educational program for Botswanan prehospital providers via written and simulation-based examinations.
We developed a two-day course based on a formal needs assessment and MOH leadership input. The subject matter of the simulation scenarios represented common calls to the prehospital system in Botswana. Didactic lectures and facilitated skills training were conducted by U.S. practitioners who also served as instructors for a rapid-cycle, deliberate practice simulation education model and simulation-based testing scenarios. Three courses, held in three cities in Botswana, were offered to off-duty MOH prehospital providers, and the participants were evaluated using written multiple-choice tests, videotaped traditional simulation scenarios, and self-efficacy surveys.
Collectively, 31 prehospital providers participated in the three courses. The mean scores on the written pretest were 67% (standard deviation SD, 10) and 85% (SD, 7) on the post-test (p < 0.001). The mean scores for the simulation were 42% (SD, 14.2) on the pretest and 75% (SD, 11.3) on the post-test (p < 0.001). Moreover, the intraclass correlation coefficient scores between reviewers were highly correlated at 0.64 for single measures and 0.78 for average measures (p < 0.001 for both). Twenty-one participants (68%) considered the course "extremely useful."
Botswanan prehospital providers who participated in this course significantly improved in both written and simulation-based performance testing. General feedback from the participants indicated that the simulation scenarios were the most useful and enjoyable aspects of the course. These results suggest that this curriculum can be a useful educational tool for teaching and reinforcing prehospital care concepts in Botswana and may be adapted for use in other resource-limited settings.
Background: A gap exists in understanding a provider's approach to delivering care that is mutually beneficial to patients, families, and other providers in the prehospital setting. The purpose of ...this study was to identify attitudes, beliefs, and perceived barriers to providing patient and family centered care (PFCC) in the prehospital setting and to describe potential solutions for improving PFCC during critical pediatric events. Methods: We conducted a qualitative, cross-sectional study of a purposive sample of Emergency Medical Technicians (EMTs) and paramedics from an urban, municipal, fire-based EMS system, who participated in the Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPS) course. Two coders reviewed transcriptions of audio recordings from participants' first simulation scenario debriefings and performed constant comparison analysis to identify unifying themes. Themes were verified through member checking with two focus groups of prehospital providers. Results: A total of 122 EMTs and paramedics participated in 16 audiotaped debriefing sessions and two focus groups. Four overarching themes emerged regarding the experience of PFCC by prehospital providers: (1) Perceived barriers included the prehospital environment, limited manpower, multi-tasking medical care, and concern for interference with patient care; (2) Providing emotional support comprised of empathetically comforting caregivers, maintaining a calm demeanor, and empowering families to feel involved; (3) Effective communication strategies consisted of designating a family point person, narration of actions, preempting the next steps, speaking in lay terms, summarizing during downtime, and conveying a positive first impression; (4) Tactics to overcome PFCC barriers were maintaining a line of sight, removing and returning a caregiver to and from the scene, and providing situational awareness. Conclusions: Based on debriefings from simulated scenarios, some prehospital providers identified the provision of emotional support and effective communication as important components to the delivery of PFCC. Other providers revealed several perceived barriers to providing PFCC, though potential solutions to overcome many of these barriers were also identified. These findings can be utilized to integrate effective communication and emotional support techniques into EMS protocols and provider training to overcome perceived barriers to PFCC in the prehospital setting.
Rapid cycle deliberate practice (RCDP) for teaching team-based resuscitation is associated with similar improvements in immediate performance as compared with postsimulation debriefing (PSD). Limited ...studies compare skill retention between these 2 modalities. Our objective was to compare retention of team leader performance in residents trained with RCDP versus PSD.
This was a cluster-randomized trial comparing RCDP and PSD from January 2018 to April 2019. Pediatric and emergency medicine residents participated in simulation-based pediatric resuscitation education, and teams were randomized to undergo either RCDP or PSD. Each participant's team leader performance was assessed 1 to 12 months after training via a simulated cardiac arrest. The primary outcome was time to defibrillation. Secondary outcomes included overall team leader performance and time to chest compressions.
Thirty-two residents (90.6% pediatrics, 9.4% emergency medicine) met inclusion criteria (16 RCDP, 16 PSD). Of the 32 residents, 40% returned in 1 to 3 months, 25% 3 to 6 months, 16% 6 to 9 months, and 19% 10 to 12 months. Participants in RCDP had more than 5 times the odds of achieving defibrillation versus those in the PSD group (odds ratio = 5.57, 95% confidence interval = 1.13-27.52, P = 0.04). The RCDP group had a higher mean Resident Team Leader Evaluation score (0.54 ± 0.19) than the PSD group (0.34 ± 0.16, P < 0.001).
This study shows significant differences in subsequent performance in the team leader trained with RCDP and suggests that RCDP may improve retention of pediatric resuscitation skills compared with PSD. Future studies should focus on best applications for RCDP with attention to knowledge and skill decay.
Graduate medical education faces challenges as programs transition to the next accreditation system. Evidence supports the effectiveness of simulation for training and assessment. This study aims to ...describe the current use of simulation and barriers to its implementation in pediatric emergency medicine (PEM) fellowship programs.
A survey was developed by consensus methods and distributed to PEM program directors via an anonymous online survey.
Sixty-nine (95%) fellowship programs responded. Simulation-based training is provided by 97% of PEM fellowship programs; the remainder plan to within 2 years. Thirty-seven percent incorporate >20 simulation hours per year. Barriers include the following: lack of faculty time (49%) and faculty simulation experience (39%); limited support for learner attendance (35%); and lack of established curricula (32%). Of those with written simulation curricula, most focus on resuscitation (71%), procedures (63%), and teamwork/communication (38%). Thirty-seven percent use simulation to evaluate procedural competency and resuscitation management. PEM fellows use simulation to teach (77%) and have conducted simulation-based research (33%). Thirty percent participate in a fellows' "boot camp"; however, finances (27%) and availability (15%) limit attendance. Programs receive simulation funding from hospitals (47%), academic institutions (22%), and PEM revenue (17%), with 22% reporting no direct simulation funding.
PEM fellowships have rapidly integrated simulation into their curricula over the past 5 years. Current limitations primarily involve faculty and funding, with equipment and dedicated space less significant than previously reported. Shared curricula and assessment tools, increased faculty and financial support, and regionalization could ameliorate barriers to incorporating simulation into PEM fellowships.
Background. For uncommon events in medicine, such as pediatric CPR, more frequent training is associated with improved performance among healthcare providers and physicians in training. Gamified ...learning may facilitate motivation to practice CPR, though studies to support this are lacking.
Intervention. Residents were interviewed to understand motivating factors for CPR practice outside of a traditional classroom certification setting.
Methods. We used a qualitative study design within a larger multinational study. Semi-structured, one-on-one interviews were completed with pediatric residents using a constructivist approach. Transcripts were reviewed independently by two authors (IHG, JLS).
Results. The inductive framework gradually moved away from gamification and towards that of self-determination. Participating residents reported several types of intrinsic and extrinsic motivational drivers towards practicing CPR, such as practicing CPR to prepare, or as a connection to clinical practice. Some themes were amotivational, such as performance anxiety, and detracted from their drive to practice. Despite a gamification design to this curriculum, these components were rarely mentioned. These themes related to achieving Maslow’s three psychological needs of autonomy, relatedness and competence.
Conclusion. The motivation to practice CPR among residents aligns with the self-determination theory. By stimulating intrinsic motivating factors, future curriculum design may better motivate residents to practice CPR.
Objectives
Asynchronous e‐learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e‐learning curriculum has not been ...studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e‐learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers.
Methods
Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four‐group design. The experimental arms received an asynchronous e‐learning curriculum consisting of nine Web‐based, interactive, peer‐reviewed Flash/HTML5 modules. Postrotation testing and in‐training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores.
Results
A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e‐learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e‐learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval CI = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η2 = 0.19). Posttest scores correlated with ITE scores (r2 = 0.14, p < 0.001) among pediatric residents.
Conclusions
Asynchronous e‐learning is an effective educational tool to improve knowledge in a clinical rotation. Web‐based asynchronous e‐learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in‐hospital learning.
Resumen
Objetivos
El aprendizaje electrónico asincrónico (AEA) permite la docencia dirigida y es particularmente ventajoso cuando la formación didáctica y a pie de cama es insuficiente. No se ha estudiado un plan de estudios de AEA en muchos centros en el contexto de un rotación clínica. La hipótesis fue que un plan de estudios de AEA durante la rotación en Medicina de Urgencias y Emergencias (MUE) Pediátrica mejora el conocimiento médico entre los residentes y estudiantes en los numerosos centros participantes.
Metodología
Se asignaron aleatoriamente los alumnos que rotaron en MUE Pediátrica a cuatro grandes centros pediátricos de 2012 a 2013 siguiendo un diseño Solomon‐4‐group. El brazo experimental recibió un plan de estudios AEA consistente en nueve módulos con formato Flash/HTML5, revisados por pares, interactivos y basados en la web. Los exámenes tras la rotación y las puntuaciones del examen durante la rotación (In‐Training Examination (ITE)) cuantificaron las mejoras del conocimiento. Una ANCOVA 2 × 2 comprobó la interacción y los efectos principales y la correlación de Pearson testó las asociaciones entre el uso de los módulos, las calificaciones y las puntuaciones del ITE.
Resultados
De los 458 participantes, 256 completaron todos los elementos del estudio: 104 tuvieron acceso a los módulos de AEA y 152 fueron controles que siguieron la formación actual habitual. No se encontró sensibilización pretest (p = 0,75). El uso de módulos de AEA se asoció con una mejora en las puntuaciones postest (p < 0,001), desde una puntuación media de 18,45 (IC 95% = 17,92 a 18,98) a 21,30 (IC 95% = 20,69 a 21,91), lo que supone un gran efecto (η2 parcial = 0,19). Entre los residentes de pediatría, las puntuaciones postest se correlacionaron con las puntuaciones ITE (r2 = 0,14, p < 0,001)
Conclusiones
El AEA es una herramienta formativa efectiva para mejorar el conocimiento en una rotación clínica. El AEA basado en la web es una modalidad prometedora para estandarizar la educación entre multitud de instituciones con planes de estudios comunes, particularmente en rotaciones clínicas donde las dificultades de programación, la estacionalidad y las experiencias variables limitan el aprendizaje intrahospitalario.
Background: A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in ...Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training. Objectives: The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs). Methods: This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ
2
test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous). Results: Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study. Conclusion: Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence. Key words: seizure; emergency medical services; simulation; pediatrics
Necrotizing enterocolitis (NEC) is a gastrointestinal emergency most commonly seen in premature infants, but equally important to recognize in term infants. Early diagnosis and management is critical ...to achieving optimal patient outcomes. This report outlines a simulation of the challenging scenario of a term infant presenting to the emergency center with NEC as a result of bacteremia and sepsis due to a urinary tract infection (UTI). This simulation can be used for teaching different levels of learners including novice, intermediate, and advanced. It focuses on the presentation, diagnosis, and emergent management of NEC, and additionally incorporates Pediatric Advanced Life Support (PALS) for more advanced learners.
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