A multicenter simulation-based research study to assess the ability of interprofessional code-teams and individual members to perform high-quality CPR (HQ-CPR) at baseline and following an ...educational intervention with a CPR feedback device.
Five centers recruited ten interprofessional teams of AHA-certified adult code-team members with a goal of 200 participants. Baseline testing of chest compression (CC) quality was measured for all individuals. Teams participated in a baseline simulated cardiac arrest (SCA) where CC quality, chest compression fraction (CCF), and peri-shock pauses were recorded. Teams participated in a standardized HQ-CPR and abbreviated TeamSTEPPS® didactic, then engaged in deliberate practice with a CPR feedback device. Individuals were assessed to determine if they could achieve ≥80% combined rate and depth within 2020 AHA guidelines. Teams completed a second SCA and CPR metrics were recorded. Feedback was disabled for assessments except at one site where real-time CPR feedback was the institutional standard. Linear regression models were used to test for site effect and paired t-tests to evaluate significant score changes. Logistic univariate regression models were used to explore characteristics associated with the individual achieving competency.
Data from 184 individuals and 45 teams were analyzed. Baseline HQ-CPR mean score across all sites was 18.5% for individuals and 13.8% for teams. Post-intervention HQ-CPR mean score was 59.8% for individuals and 37.0% for teams. There was a statistically significant improvement in HQ-CPR mean scores of 41.3% (36.1, 46.5) for individuals and 23.2% (17.1, 29.3) for teams (p<0.0001). CCF increased at 3 out of 5 sites and there was a mean 5-s reduction in peri-shock pauses (p<0.0001). Characteristics with a statistically significant association were height (p=0.01) and number of times performed CPR (p=0.01).
Code-teams and individuals struggle to perform HQ-CPR but show improvement after deliberate practice with feedback as part of an educational intervention. Only one site that incorporated real-time CPR feedback devices routinely achieved ≥80% HQ-CPR.
Abstract Interprofessional team training in medicine evolved out of crisis resource management (CRM) principles initially utilized in the aviation industry to improve teamwork and communication ...skills. With the 1999 publication of the Institute of Medicine report, To Err is Human: Building a Safer Health System, there has been an ever increasing focus on the negative impact of communication and teamwork on the rate of medical error and quality of patient care. With this is mind, there is a growing acknowledgement of the need for training in these critical skills. Recently, simulation-based team training programs have been developed across a variety of disciplines, including anesthesia, surgery, emergency medicine and pediatric emergency medicine. As the number and spectrum of these programs has increased, best practices for high quality training programs have been published including: practice recommendations for curriculum design, scenario design, feedback and debriefing. Assessment tools have also been developed to evaluate the quality of these teamwork behaviors, as well as the potential impact of these programs. Although the impact of simulation-based interprofessional team training on actual patient care has been investigated in several studies, it is clear that further work is needed to fully evaluate the effect of this training and the best techniques and processes to accomplish the objectives of high quality healthcare for all.
Simulation-based education often relies on confederates, who provide information or perform clinical tasks during simulation scenarios, to play roles. Although there is experience with confederates ...in their more routine performance within educational programs, there is little literature on the training of confederates in the context of simulation-based research. The CPR CARES multicenter research study design included 2 confederate roles, in which confederates' behavior was tightly scripted to avoid confounding primary outcome measures. In this report, we describe our training process, our method of adherence assessment, and suggest next steps regarding confederate training scholarship.
High-fidelity medical simulation is a technique used for training residents. Simulation is used to teach procedural skills and teamwork. There are limited data on the efficacy of this educational ...technique. We hypothesize that simulation is effective for teaching pediatric residents airway skills and teamwork.
We performed a randomized crossover trial with 16 postgraduate year 2 residents at the Rhode Island Hospital Medical Simulation Center. The residents were given a standard introduction to the simulation center then managed 2 scenarios, during which baseline airway and teamwork skills were assessed. The participants were divided into 2 groups. Group 1 returned for a simulation-enhanced session on pediatric airway management and teamwork, whereas group 2 received no supplemental education. Two months later, groups 1 and 2 were reassessed. Subsequently, group 2 returned for the same intervention as group 1. Both groups returned for a final assessment.
Data were collected using the Rhode Island Hospital Medical Simulation Center global competency score, critical action checklists, harmful actions lists, and the Behaviorally Anchored Rating Scale. The mean global competency score improved and showed a statistically significant relationship between the intervention and the performance. Critical actions showed a statistically insignificant trend of improvement. There was a striking reduction in the number of harmful actions. The Behaviorally Anchored Rating Scale improved at each session though statistically unrelated to the intervention.
This study supports simulation-enhanced educational strategies for improving performance and teamwork skills. This technique is effective in teaching pediatric residents airway skills and teamwork fundamentals required to efficiently manage an acute airway situation.
IntroductionThe Accreditation Council for Graduate Medical Education has identified the need for assessment of core skills for pediatric and emergency medicine residents, which includes pediatric ...airway management. Although there are standard courses for pediatric airway management, there is no validated tool to assess basic and advanced pediatric airway skills performance. Our objective was to develop a simulation-based tool for the formative assessment of resident pediatric airway skills performance that was concise, yet comprehensive, and to evaluate the evidence supporting the argument for the tool's validity. MethodsWe developed a pediatric airway assessment tool (PAAT) to assess six major domains of pediatric airway skills performance: basic airway maneuvers, airway adjuncts, bag-valve mask ventilation, advanced airway equipment preparation, direct laryngoscopy, and video laryngoscopy. This tool consisted of a 72-item pediatric airway skills assessment checklist to be used in simulation. We enrolled 12 subjects at four different training levels to participate. Assessment scores were rated by two independent expert raters. ResultsThe interrater agreement was high, ranging from 0.92 (adult bagging rate) to 1 (basic airway maneuvers). There was a significant trend of increasing scores with increased training level. DiscussionThe PAAT demonstrated excellent interrater reliability and provided evidence of the construct's validity. Although further validation of this assessment tool is needed, these results suggest that the PAAT may eventually be useful for assessment of resident proficiency in pediatric airway skills performance.
To evaluate high-fidelity medical simulation as an assessment tool for pediatric residents' ability to manage an acute airway.
We performed a prospective, observational study in which 16 pediatric ...residents were consented and then brought to the medical simulation center. They were placed in 2 different computer-driven scenarios and asked to manage the cases. The first scenario was a 3-month-old infant with bronchiolitis and severe respiratory distress and was programmed to develop respiratory failure. The second case was a 16-year-old adolescent with alcohol intoxication and respiratory depression and was programmed for emesis and aspiration. Both cases included a nurse, parent, and intern. We recorded performance of predetermined critical actions and any harmful actions.
There were 47 attempts at intubation with 27 successes (56%). Appropriate preoxygenation was performed in 15 (47%) of 32 cases. Appropriate rapid sequence induction was administered in 21 (66%) of 32 cases. Cricoid pressure was applied in 20 (63%) of 32 cases. End-tidal carbon dioxide detector was used in 11 (34%) of 32 cases. A nasogastric tube was placed in 14 (44%) of 32 cases. Harmful actions included rapid sequence induction administered before intubation equipment setup, bag-valve mask not connected to oxygen, inappropriate endotracheal tube size, pulling cuffed endotracheal tube out while inflated, and placing the laryngoscope blade on backwards.
Our data identified many areas of concern with resident skills in managing an airway. This project suggests that high-fidelity medical simulation can assess a resident's ability to manage an airway as well as a program's effectiveness in teaching the skills necessary to manage an acute pediatric airway.
Objective To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. Study design This was a ...retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. Results A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = −3.23; 95% confidence interval CI = −4.48 to −1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the “other” category (difference = −3.34, 95% CI = −5.40 to −1.27 and −3.12, 95% CI = −5.25 to −0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = −2.75; 95% CI = −5.40 to −0.05). Older children received better care. Conclusions The quality of care provided to children is associated with age, hospital setting, and physician training.
Abstract Introduction Burn management and airway management are commonly encountered in busy emergency departments, and although emergency airway management is a mainstay of care in critically burned ...patients, inhaled toxins may be less immediately considered. This simulation case is designed to help remind emergency physicians of the various ways that house fires can be deadly, focusing on inhaled toxins. The simulated patient in this scenario is free of external burns but nonetheless requires critical care and attention to the cellular asphyxiants that can be encountered in inhalational injuries. Methods This simulation scenario involves a 16-year-old boy suffering the ill effects of inhaled toxins, including carbon monoxide and cyanide. Learners must perform a rapid basic assessment for evidence of burn injuries, provide initial critical care, identify the likelihood of inhalation toxicity—both carbon monoxide and cyanide—and initiate directed therapy, including preparation for hyperbaric therapy and antidotes to cyanide. The case was developed using the Laerdal SimMan and associated software but can be easily adapted to a variety of low- or high-fidelity simulation manikins. Included in the case are the associated program files, PowerPoint slides, and pictures. The encounter should take approximately 15-20 minutes to complete. Results This case has been run with a cohort of pediatric emergency medicine fellows as active participants. A junior fellow was the primary learner in the case, with a senior fellow as a backup physician. Passive participants, including pediatric emergency medicine attending physicians and fellows, observed the simulation via video link and actively participated in the debriefing. In total, there have been four active learners and approximately 15 passive learners for the case. Both active and passive learners provided feedback, stating that the case was realistic and relevant to their learning. Discussion The case is most suitable for emergency medicine residents or pediatric emergency medicine fellows. With adjustments appropriate to the level of learner, it may also be targeted toward senior medical students, prehospital emergency personnel, or emergency medicine residents The focus on critical care and airway management suggests that use of the case could be suitable for senior pediatric residents or trainees in pediatric critical care, although it has not been piloted in these populations of learners.
Advanced medical simulation has become widespread. One development, the adaptation of simulation techniques and manikin technologies for portable operation, is starting to impact the training of ...personnel in acute care fields such as emergency medicine (EM) and trauma surgery. Unencumbered by cables and wires, portable simulation programs mitigate several limitations of traditional (nonportable) simulation and introduce new approaches to acute care education and research.
Portable simulation is already conducted across multiple specialties and disciplines. In situ medical simulations are those carried out within actual clinical environments, while off‐site portable simulations take place outside of clinical practice settings. Mobile simulation systems feature functionality while moving between locations; progressive simulations are longer‐duration events using mobile simulations that follow a simulated patient through sequential care environments. All of these variants have direct applications for acute care medicine.
Unique training and investigative opportunities are created by portable simulation through four characteristics: 1) enhancement of experiential learning by reframing training inside clinical care environments, 2) improving simulation accessibility through delivery of training to learner locations, 3) capitalizing on existing care environments to maximize simulation realism, and 4) provision of improved training capabilities for providers in specialized fields. Research agendas in acute care medicine are expanded via portable simulation’s introduction of novel topics, new perspectives, and innovative methodologies.
Presenting opportunities and challenges, portable simulation represents an evolutionary progression in medical simulation. The use of portable manikins and associated techniques may increasingly complement established instructional measures and research programs at acute care institutions and simulation centers.
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