The use of simulation for pediatric training and assessment

Significant Reduction of Catheter-associated Blood Stream Infections in Preterm Neonates After Implementation of a Care Bundle Focusing on Simulation Training of Central Line Insertion

BACKGROUND

Central line-associated blood stream infections (CLABSIs) are common problems in neonatal intensive care units (NICUs). Implementation of catheter care bundles has been shown to reduce CLABSI rates. We developed a care bundle aiming at establishing a uniform central line insertion technique and improving teaching practices focusing on simulation-based techniques. The purpose of this study was to assess the impact of this care bundle on CLABSI rates in very low birth weight infants (VLBWI).

METHODS

In September 2010, a CLABSI prevention bundle was introduced in our NICU, consisting of simulation-based standardization and education of a peripherally inserted central catheter insertion technique. Data of all VLBWI admitted to our NICU during 2010-2012 were analyzed. Diagnosis of CLABSI required a positive blood culture in the presence of a central venous catheter and clinical signs of infection.

RESULTS

Five hundred twenty-six VLBWI admitted during the study period were included into the analysis. CLABSI rates decreased significantly from 13.9 in 2010 to 9.5 in 2011 and 4.7 in 2012 (P < 0.0001). This significant reduction was true for the overall population and for subgroups separated by birth weight. Distribution of blood culture pathogens revealed a constant absolute and relative decline of infections with coagulase-negative staphylococci from 2010 (n = 43/50, 86%) to 2012 (n = 12/18, 67%), as opposed by a slight increase of Staphylococcus aureus infections (n = 1/50, 2% in 2010 versus n = 2/18, 11% in 2012).

CONCLUSION

Our data provide evidence of a potential effect of simulation-based training of central line placement in decreasing CLABSI rates in VLBWI and encourage its implementation into care bundles.

Exploring the use of standardized patients for simulation-based learning in preparing advanced practice nurses

The use of standardized patients for simulation-based learning was integrated into the Master of Nursing curriculum in the 2012-2013 academic year. The study aimed to explore the Master of Nursing students' experiences with and perceptions of using standardized patients in simulations, and to identify the students' learning needs in preparing to become advanced practice nurses. The study adopted an exploratory descriptive qualitative design, using a focus group interview. The study was conducted at a university in Singapore. Seven Master of Nursing students who were enrolled in the Acute Care Track of Master of Nursing program in the 2012-2013 academic year participated in the study. The data were gathered at the end of the first semester. Content analysis was used to analyze the data. Three main categories - usefulness, clinical limitations, and realism - were identified in the study. The results revealed that the students felt using standardized patients was useful and realistic for developing skills in history taking, communication, and responding to an emergency situation. On the other hand, they found that the standardized patients were limited in providing critical signs and symptoms of case scenarios. To meet the learning objectives, future development and integration of standardized patients in the Master of Nursing curriculum might need to be considered along with the use of a high-fidelity simulator. This can be an alternative strategy to fill the gaps in each method. Obviously, using standardized patients for simulation-based learning has added value to the students' learning experiences. It is highly recommended that future studies explore the impact of using standardized patients on students' performance in clinical settings.

Dutch paediatrician's opinions about acute care for critically ill children in general hospitals

Paediatricians in general hospitals have limited experience with critically ill children, due to the low incidence and their diversity in age, pathology and presentation. Consequently, adequate organization, training and materials and medication are of major importance. This voluntary and anonymous survey-based study was conducted to gain insight in the current status of these aspects. In June 2012, all 687 paediatricians employed at 84 general hospitals in The Netherlands received a hardcopy questionnaire with questions relating to demographics, organization, training and materials and medication concerning the acute care for critically ill children. Of the sent questionnaires, 41.3% were eligible for analysis. According to the organization of the acute care of critically ill children, 73.9% of the respondents indicated verbal agreements were made, of which 77.0% stated that these were recorded in written protocols. Taskforces were present according to 64.5% of our respondents. Of the respondents, 64.4% were Advanced Paediatric Life Support (APLS) certified. Of the stated training scenarios, 90.8% were available in their hospital, which were followed on a regular basis by 63.9% of the paediatricians. Paediatric resuscitation carts were present on both emergency department and paediatric ward according to 95.1%. Materials (37.7%) and medication (45.3%) were frequently lacking.

CONCLUSION

Paediatricians from general hospitals in The Netherlands consider that acute care for critically ill children has to be improved in terms of organization, training and teamwork, and medication and materials. National guidelines concerning the organization and training may contribute to this improvement, as well as a standardized inventory list for paediatric resuscitation carts.

The Academic Half-Day redesigned: Improving generalism, promoting CanMEDS and developing self-directed learners

BACKGROUND

The Montreal Children's Hospital Pediatric Residency Program redesigned its Academic Half-Day based on program concerns consistent with the published literature. These concerns included inadequate preparation for general paediatric practice, gaps in CanMEDS education and exclusive use of didactic lectures. Novel instructional methods included monthly simulation sessions to learn CanMEDS competencies, increased use of general paediatricians as instructors, implementation of a 'systems-based' curriculum and development of self-directed learning skills through activities such as 'Residents as Teachers'.

METHOD

A postimplementation online survey was sent to all 18 residents who had been exposed to both curricula. The survey was designed to determine the impact of the new curriculum on their perceived ability to retain information and acquire the competencies of a general paediatrician, and to assess the effect on their self-directed learning. Responses were recorded on a five-point Likert scale ranging from 'strongly disagree' to 'strongly agree'.

RESULTS

Fourteen of 18 (78%) residents completed the survey. All residents preferred the 'systems-based' educational program. Seventy-nine percent of all residents agreed that the simulation sessions were an effective method of learning the CanMEDS competencies. Importantly, 64% of residents voluntarily read more about the topics presented and 71% agreed that they retained the content better. Moreover, 79% believed that changes made to the teaching curriculum better prepared them for a general paediatric practice and 64% of residents believed that it better 'supplements' learning in the clinical setting.

CONCLUSION

The authors propose that the new curriculum is comprehensive, while developing the skills required for life-long learning as a general paediatrician.

Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum

ISSUE

Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents' rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor.

EVIDENCE

A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm(3), and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) (n = 71).

IMPLICATIONS

We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.

Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care.

CONCLUSIONS

The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.

Use of simulation-based education: a national survey of pediatric clerkship directors

OBJECTIVE

To document the prevalence of simulation-based education (SBE) for third- and fourth-year medical students; to determine the perceived importance of SBE; to characterize the barriers associated with establishing SBE.

METHODS

A 27-item survey regarding simulation was distributed to members of the Council on Medical Student Education in Pediatrics (COMSEP) as part of a larger survey in 2012.

RESULTS

Seventy-one (48%) of 147 clerkship directors (CD) at COMSEP institutions responded to the survey questions regarding the use of SBE. Eighty-nine percent (63 of 71) of CDs reported use of SBE in some form: 27% of those programs (17 of 63) reported only the use of the online-based Computer-Assisted Learning in Pediatrics Program, and 73% (46 of 63) reported usage of other SBE modalities. Fifty-four percent of CDs (38 of 71) agreed that SBE is necessary to meet the requirements of the Liaison Committee on Medical Education (LCME). Multiple barriers were reported in initiating and implementing an SBE program.

CONCLUSIONS

SBE is commonly used for instruction during pediatric undergraduate medical education in North American medical schools. Barriers to the use of SBE remain despite the perception that it is needed to meet requirements of the LCME.

Technology-enhanced simulation and pediatric education: a meta-analysis

BACKGROUND AND OBJECTIVE

Pediatrics has embraced technology-enhanced simulation (TES) as an educational modality, but its effectiveness for pediatric education remains unclear. The objective of this study was to describe the characteristics and evaluate the effectiveness of TES for pediatric education.

METHODS

This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. A systematic search of Medline, Embase, CINAHL, ERIC, Web of Science, Scopus, key journals, and previous review bibliographies through May 2011 and an updated Medline search through October 2013 were conducted. Original research articles in any language evaluating the use of TES for educating health care providers at any stage, where the content solely focuses on patients 18 years or younger, were selected. Reviewers working in duplicate abstracted information on learners, clinical topic, instructional design, study quality, and outcomes. We coded skills (simulated setting) separately for time and nontime measures and similarly classified patient care behaviors and patient effects.

RESULTS

We identified 57 studies (3666 learners) using TES to teach pediatrics. Effect sizes (ESs) were pooled by using a random-effects model. Among studies comparing TES with no intervention, pooled ESs were large for outcomes of knowledge, nontime skills (eg, performance in simulated setting), behaviors with patients, and time to task completion (ES = 0.80-1.91). Studies comparing the use of high versus low physical realism simulators showed small to moderate effects favoring high physical realism (ES = 0.31-0.70).

CONCLUSIONS

TES for pediatric education is associated with large ESs in comparison with no intervention. Future research should include comparative studies that identify optimal instructional methods and incorporate pediatric-specific issues into educational interventions.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

Expanding the role of objectively structured clinical examinations in nephrology training

Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that contains both examination and training features and focuses on management and clinical knowledge of rare hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in managing the event. The OSCE tested and trained fellows in the recognition and management of rare hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty training; however, collaboration between training programs would be necessary to validate such exercises.

Comparison of success rates using video laryngoscopy versus direct laryngoscopy by residents during a simulated pediatric emergency

OBJECTIVE

Emergency airway situations are relatively rare events in pediatrics with most graduating residents having little exposure to intubate. Newer video technology offers the promise of reducing complications associated with intubation. This study proposes that video laryngoscopy (VL) should aid less skilled residents to intubate an infant mannequin with greater success and speed as compared with traditional direct laryngoscopy (DL).

METHODS

Pediatric (PED) and emergency medicine (EM) residents were randomized in a prospective controlled study. A standard respiratory failure scenario was conducted using SimBaby with an uncomplicated airway. Residents who inadvertently performed esophageal intubation were made aware as part of the scenario and allowed to reattempt until successful.

RESULTS

Sixty-nine residents voluntarily participated, 49% EM and 51% PED. Seven subjects in the DL group required multiple attempts (21%), compared with 6 subjects in the VL group (17%) (P = 0.718). Median time to intubation was 30 seconds (95% confidence interval [CI], 19-41 seconds) for DL and 39 seconds (95% CI, 36-42 seconds) for VL (P = 0.111). Comparison of programs revealed a 77% PED success rate versus 85% EM success rate (P = 0.578) and median time to intubation of 38 seconds (95% CI, 31-45 seconds) for PED compared with 32 seconds (95% CI, 23-41 seconds) for EM residents (P = 0.316). In a subanalysis, subjects successful at first attempt revealed a 13-second median difference (DL, 23 seconds [95% CI, 18-28 seconds] vs. VL, 36 seconds [95% CI, 29-43 seconds; P = 0.01).

CONCLUSIONS

In a simulated respiratory failure scenario involving residents, VL provided no additional success over DL with slightly longer time to intubation.

Effect of focused debriefing on team communication skills

BACKGROUND AND OBJECTIVE

Community hospitals often lack tertiary care support such as pediatric intensivists and anesthesiologists. Resuscitation of critically ill and injured children in community hospitals requires a well-coordinated team effort, because good team performance improves quality of care. The lack of subspecialty support makes team coordination and communication more imperative yet much more challenging. This study sought to determine if the addition of a defined focused post-mock code debriefing session improved communication skills among team members in a community pediatric emergency department.

METHODS

Twenty-two volunteer members of the pediatric emergency and respiratory therapy departments at Medstar Franklin Square Medical Center took part in monthly simulated resuscitations for 3 consecutive months. After each simulation, participants answered an 18-item survey on observed communication among their team members. Members then participated in a 30-minute debriefing session in which they reflected on their own communication skills. A video taping of the resuscitation was later scored by one of the investigators by using a rubric designed by the investigators. Descriptive statistics were calculated for both the participant survey and the team communication indicator scores. Paired-sample Wilcoxon signed rank test examined the difference in the scores between each of 3 sessions.

RESULTS

The mean scores by investigator-scored video recordings of the teams' mock resuscitation by session showed overall team communication improved between sessions 1 and 3 for all communication areas (P = .03), with significant improvement in 4 of 9 communication areas by the third session. All team members improved communication skills as well, with the greatest improvement by the clinical multifunctional technicians.

CONCLUSIONS

Communication skills improve with the addition of focused debriefing sessions after mock codes as perceived by participants during debriefing sessions and evidenced by investigator-scored video recordings of resuscitations.

Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios

AIM

Life threatening paediatric emergencies are relatively uncommon events. When they do occur staff caring for these children must have the ability to recognise the deterioration, evaluate and simultaneously treat these patients. The aim of this study was to identify suboptimal care during standardised simulated scenarios and to identify the potential causation factors.

METHODS

Participants were emergency department and operating theatre staff in Sydney, Australia. Incidents of suboptimal care were identified during scenarios and were analysed by thematic qualitative assessment methods. Potential causation factors were elicited both during and immediately after the scenarios and during facilitated debriefings. Causation factors were attributed to any of seven pre-defined categories.

RESULTS

Seventy-three simulations occurred over 9 month period in 2011. 270 doctors, 235 nurses and 11 students participated. 194 incidents of suboptimal care were observed and attributed to 325 causation factors. There were 76 knowledge deficits, 39 clinical skill deficits, 36 leadership problems, 84 communication failures, 20 poor resource utilisations, 23 preparation and planning failures and 47 incidents of a loss of situational awareness. Clinically important themes were: paediatric life support, drug choice and doses, advanced airway and ventilation, intravenous fluids and recognition of the deteriorating patient. Recurring incidents included the failure to recognise a cardiac arrest, inadequate fluid resuscitation and incorrect medication dose administration.

CONCLUSIONS

During standardised paediatric simulations multiple incidents of suboptimal care have been identified and multiple causation factors attributed to these. Educators should use this information to adapt current training programs to encompass these factors.

Impact of simulation training on time to initiation of cardiopulmonary resuscitation for first-year pediatrics residents

BACKGROUND

Pediatrics residents have few opportunities to perform cardiopulmonary resuscitation (CPR). Enhancing the quality of CPR is a key factor to improving outcomes for cardiopulmonary arrest in children and requires effective training strategies.

OBJECTIVE

To evaluate the effectiveness of a simulation-based intervention to reduce first-year pediatrics residents' time for 3 critical actions in CPR: (1) call for help, (2) initiate bag-mask ventilation, and (3) initiate chest compressions.

METHODS

A prospective study involving 31 first-year pediatrics residents at a children's hospital assigned to an early or late (control) intervention group. Residents underwent baseline assessment followed by repeat evaluations at 3 and 6 months. Time to critical actions was scored by video review. A 90-minute educational intervention focused on skill practice was conducted following baseline evaluation for the early-intervention group and following 3-month evaluation for the late-intervention group. Primary outcome was change in time to initiating the 3 critical actions. Change in time was analyzed by comparison of Kaplan-Meier curves, using the log-rank test. A 10% sample was timed by a second rater. Agreement was assessed using intraclass correlation (ICC).

RESULTS

There was a statistically significant reduction in time for all 3 critical actions between baseline and 3-month evaluation in the early intervention group; this was not observed in the late (control) group. Rater agreement was excellent (ICC ≥ 0.99).

CONCLUSIONS

A simulation-based educational intervention significantly reduced time to initiation of CPR for first-year pediatrics residents. Simulation training facilitated acquisition of critical CPR skills that have the potential to impact patient outcome.

Simulation training for pediatric residents on central venous catheter placement: a pilot study

OBJECTIVE

To assess the effect of simulation training on pediatric residents' acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure.

DESIGN

Prospective observational pilot study.

SETTING

Single university clinical simulation center.

SUBJECTS

Pediatric residents, postgraduate years 1-3.

INTERVENTIONS

Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale.

MEASUREMENTS AND MAIN RESULTS

Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 83.3% [interquartile range, 70.0-91.7%]), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 79.5 mm [interquartile range, 16.3-91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8-19.0 mm] vs 52.0 mm [interquartile range, 43.5-66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 54.2% [interquartile range, 45.8-80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 35.5 mm [interquartile range, 5.3-77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8-19.0 mm] vs 61.0 mm [interquartile range, 31.5-71.8 mm], p < 0.01).

CONCLUSIONS

Simulation training improved pediatric residents' central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Treatment of a simulated child with anaphylaxis: an in situ two-arm study

AIM

This study aims to determine whether junior medical staff correctly identify and treat paediatric anaphylaxis and whether the presence or absence of hypotension influenced the treatment, using a standardised simulated patient encounter.

METHODS

Junior medical staff from the emergency department of a large paediatric tertiary hospital were invited to participate in a two-armed cohort study to assess recognition and management of anaphylaxis in a standardised scenario using a simulated patient with and without hypotension. The primary outcome measure was administration of adrenaline. The secondary outcome measures included time to adrenaline administration, ability to seek and identify relevant features of history and clinical examination and use of other medications.

RESULTS

Fifty-six junior medical staff participated (90% participation rate). Only 50% of participants administered adrenaline in scenarios of definite anaphylaxis. Adrenaline was more likely to be administered if the scenario included hypotension, where the junior medical officer had previous formal resuscitation training (Advanced Paediatric Life Support) and by medical officers with more years of training.

CONCLUSION

Anaphylaxis is a life-threatening presentation and requires prompt recognition and appropriate adrenaline administration. Junior medical staff may require more emphasis on recognition and prompt adrenaline administration in both undergraduate and in hospital training and education. Simulated scenarios may provide a platform to deliver this training to ultimately improve patient care.

The effects of simulated patients and simulated gynecologic models on student anxiety in providing IUD services

INTRODUCTION

Midwifery students experience high levels of stress during their initial clinical practices. Addressing the learner's source of anxiety and discomfort can ease the learning experience and lead to better outcomes. The aim of this study was to find out the effect of a simulation-based course, using simulated patients and simulated gynecologic models on student anxiety and comfort while practicing to provide intrauterine device (IUD) services.

METHODS

Fifty-six eligible midwifery students were randomly allocated into simulation-based and traditional training groups. They participated in a 12-hour workshop in providing IUD services. The simulation group was trained through an educational program including simulated gynecologic models and simulated patients. The students in both groups then practiced IUD consultation and insertion with real patients in the clinic. The students' anxiety in IUD insertion was assessed using the "Spielberger anxiety test" and the "comfort in providing IUD services" questionnaire.

RESULTS

There were significant differences between students in 2 aspects of anxiety including state (P < 0.001) and trait (P = 0.024) and the level of comfort (P = 0.000) in providing IUD services in simulation and traditional groups. "Fear of uterine perforation during insertion" was the most important cause of students' anxiety in providing IUD services, which was reported by 74.34% of students.

CONCLUSIONS

Simulated patients and simulated gynecologic models are effective in optimizing students' anxiety levels when practicing to deliver IUD services. Therefore, it is recommended that simulated patients and simulated gynecologic models be used before engaging students in real clinical practice.

Can a rescuer or simulated patient accurately assess motion during cervical spine stabilization practice sessions?

CONTEXT

Health care providers must be prepared to manage all potential spine injuries as if they are unstable. Therefore, most sport teams devote resources to training for sideline cervical spine (C-spine) emergencies.

OBJECTIVE

To determine (1) how accurately rescuers and simulated patients can assess motion during C-spine stabilization practice and (2) whether providing performance feedback to rescuers influences their choice of stabilization technique.

DESIGN

Crossover study.

SETTING

Training studio.

PATIENTS OR OTHER PARTICIPANTS

Athletic trainers, athletic therapists, and physiotherapists experienced at managing suspected C-spine injuries.

INTERVENTION(S)

Twelve lead rescuers (at the patient's head) performed both the head-squeeze and trap-squeeze C-spine stabilization maneuvers during 4 test scenarios: lift-and-slide and log-roll placement on a spine board and confused patient trying to sit up or rotate the head.

MAIN OUTCOME MEASURE(S)

Interrater reliability between rescuer and simulated patient quality scores for subjective evaluation of C-spine stabilization during trials (O = best, 10 = worst), correlation between rescuers' quality scores and objective measures of motion with inertial measurement units, and frequency of change in preference for the head-squeeze versus trap-squeeze maneuver.

RESULTS

Although the weighted κ value for interrater reliability was acceptable (0.71-0.74), scores varied by 2 points or more between rescuers and simulated patients for approximately 10% to 15% of trials. Rescuers' scores correlated with objective measures, but variability was large: 38% of trials scored as 0 or 1 by the rescuer involved more than 10° of motion in at least 1 direction. Feedback did not affect the preference for the lift-and-slide placement. For the log-roll placement, 6 of 8 participants who preferred the head squeeze at baseline preferred the trap squeeze after feedback. For the confused patient, 5 of 5 participants initially preferred the head squeeze but preferred the trap squeeze after feedback.

CONCLUSIONS

Rescuers and simulated patients could not adequately assess performance during C-spine stabilization maneuvers without objective measures. Providing immediate feedback in this context is a promising tool for changing behavior preferences and improving training.

A delivery room-focused education and deliberate practice can improve pediatric resident resuscitation training

OBJECTIVE

To determine if deliberate practice and simulation would improve pediatric residents' neonatal resuscitation abilities.

STUDY DESIGN

Prospective cohort with pre-post-intervention design. Senior residents from 2008 to 2009 were evaluated and served as controls (C-Senior, N=23). Interns (PL-1, N=28) from 2008 to 2009 received the education and evaluation at the beginning (I-Pre) and end of their NICU rotation (I-Post) and again when they were seniors (I-Senior, N=24). The education, based on deliberate practice, included scored assessments of a resident's ability to assemble delivery room equipment and lead a simulated resuscitation.

RESULT

PL-1 equipment score increased by 30% (I-Pre; 53%, I-Post; 83%) and was not different 1 to 2 years later (I-Senior; 87%). I-Senior equipment score was 22% higher than the C-Senior group (C-Senior; 65%). The PL-1's ability to lead a resuscitation improved after the education (I-Pre; 76%, I-Post; 85%) and was maintained as senior residents (I-Senior; 85%), but was not superior to the C-Senior group (C-Senior; 81%).

CONCLUSION

The use of deliberate practice and simulation can improve a residents' resuscitation training, particularly for equipment.

The lost art of intubation: assessing opportunities for residents to perform neonatal intubation

OBJECTIVE

The objective of this study is to assess the opportunities afforded to and competence of pediatric residents in performing neonatal endotracheal intubations.

STUDY DESIGN

The records of all intubations performed on neonates over a 3-year period at a university-based birthing hospital were reviewed to assess the relationships between outcomes, types of providers and the setting of intubations.

RESULT

A total of 785 attempts were made during 362 intubations. Pediatric residents were given the opportunity to intubate 38% of the cohort (n=137) and were successful on 21% of the attempts. Residents were more likely to perform intubation in the neonatal intensive care unit (vs delivery room; P<0.001), in non-emergency situations (P<0.001), and on older (P<0.001) and larger (P=0.07) infants.

CONCLUSION

Opportunities for residents to intubate neonates were few and their success rate was low. In the current care paradigm, it is doubtful if trainees can be sufficiently skilled in endotracheal intubation during residency. Residents that plan to pursue procedure-intensive subspecialties may benefit from other models for training.

Assessment of long-term knowledge retention following single-day simulation training for uncommon but critical obstetrical events

OBJECTIVE

The objectives were to determine (i) whether simulation training results in short-term and long-term improvement in the management of uncommon but critical obstetrical events and (ii) to determine whether there was additional benefit from annual exposure to the workshop.

METHODS

Physicians completed a pretest to measure knowledge and confidence in the management of eclampsia, shoulder dystocia, postpartum hemorrhage and vacuum-assisted vaginal delivery. They then attended a simulation workshop and immediately completed a posttest. Residents completed the same posttests 4 and 12 months later, and attending physicians completed the posttest at 12 months. Physicians participated in the same simulation workshop 1 year later and then completed a final posttest. Scores were compared using paired t-tests.

RESULTS

Physicians demonstrated improved knowledge and comfort immediately after simulation. Residents maintained this improvement at 1 year. Attending physicians remained more comfortable managing these scenarios up to 1 year later; however, knowledge retention diminished with time. Repeating the simulation after 1 year brought additional improvement to physicians.

CONCLUSION

Simulation training can result in short-term and contribute to long-term improvement in objective measures of knowledge and comfort level in managing uncommon but critical obstetrical events. Repeat exposure to simulation training after 1 year can yield additional benefits.

[Systematic assessment of the paediatrician's performance during simulated supraventricular tachycardia]

INTRODUCTION

The aims of this study are to: a) assess the quality in clinical management during a simulated scenario of acute supraventricular tachycardia (SVT) by means of a structured task-based checklist and to b) detect pitfalls and grey areas where reinforcement in training may be needed.

MATERIAL AND METHODS

We systematically reviewed SVT simulated scenarios during simulation courses between June 2008 and April 2010. Three scenarios were programmed using SimBaby® simulation system, and included stable SVT (S-SVT), stable progressing to unstable SVT (SU-SVT) and unstable SVT (U-SVT). Scenarios were evaluated by means of an 18-task checklist based on ILCOR international recommendations.

RESULTS

A total of 45 scenarios were assessed with the participation of 167 paediatricians, including 15 S-SVT, 25 SU-SVT and 5 U-SVT scenarios. Out of a total of 551 possible tasks, 328 (59.5%) were completed correctly. The mean percentage of correct tasks per scenario was 63.4 (16.7) for S-SVT, 47.8 (20.3) for SU-ST and 38.6 (31) for U-SVT (p=0.028). There were no significant differences between primary care paediatricians and hospital paediatricians. Most of the participants correctly identified non-sinus rhythm as SVT. However, important pitfalls were observed, including failure to identify haemodynamic instability in 20 out of 43 (48%) cases, an incorrect dose of adenosine in 18 out of 39 (48%), incorrect adenosine administration in 23 out of 39 (59%), and non-recognition of indication to emergent cardioversion in 15 out of 31 (48%).

CONCLUSIONS

Paediatricians are able to diagnose SVT correctly, but need to improve their skills in treatment. Systematic analysis of clinical performance in a simulated scenario allows the identification of strengths, as well as weak points, where reinforcement is needed.

High-fidelity simulation training for sleep technologists in a pediatric sleep disorders center

STUDY OBJECTIVES

Severe events of respiratory distress can be life threatening. Although rare in some outpatient settings, effective recognition and management are essential to improving outcomes. The value of high-fidelity simulation has not been assessed for sleep technologists (STs). We hypothesized that knowledge of and comfort level in managing emergent pediatric respiratory events would improve with this innovative method.

METHODS

We designed a course that utilized high-fidelity human patient simulators (HPS) and that focused on rapid pediatric assessment of young children in the first 5 minutes of an emergency. We assessed knowledge of and comfort with critical emergencies that STs may encounter in a pediatric sleep center utilizing a pre/post-test study design.

RESULTS

Ten STs enrolled in the study, and scores from the pre- and posttest were compared utilizing a paired samples t-test. Mean participant age was 42 ± 11 years, with average of 9.3 ± 3.3 years of ST experience but minimal experience in managing an actual emergency. Average pretest score was 54% ± 17% correct and improved to 69% ± 16% after the educational intervention (p < 0.05). Participant ratings indicated the course was a well-received, innovative educational methodology.

CONCLUSIONS

A simulation course focusing on respiratory emergencies requiring basic life support skills during the first 5 min of distress can significantly improve the knowledge of STs. Simulation may provide a highly useful methodology for training STs in the management of rare life-threatening events.

Simulation-based medical teaching and learning

One of the most important steps in curriculum development is the introduction of simulation- based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulation aides to replicate clinical scenarios. Although medical simulation is relatively new, simulation has been used for a long time in other high risk professions such as aviation. Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or 'fidelity'. Simulation- based learning is expensive. However, it is cost-effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider's competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.

Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies

OBJECTIVE

To examine the hypothesis that pediatric resuscitation providers hyperventilate patients via bag-valve-mask (BVM) ventilation during performance of cardiopulmonary resuscitation (CPR), quantify the degree of excessive ventilation provided, and determine if this tendency varies according to provider type.

METHODS

A retrospective, observational study was conducted of 72 unannounced, monthly simulated pediatric medical emergencies ("mock codes") in a tertiary care, academic pediatric hospital. Responders were code team members, including pediatric residents and interns (MDs), respiratory therapists (RTs), and nurses (RNs). All sessions were video-recorded and reviewed for the rate of BVM ventilation, rate of chest compressions, and the team members performing these tasks. The type of emergency, location of the code, and training level of the team leader were also recorded.

RESULTS

Hyperventilation was present in every mock code reviewed. The mean rate of BVM ventilation for all providers in all scenarios was 40.6 ± 11.8 breaths per minute (BPM). The mean ventilation rates for RNs, RTs, and MDs were 40.8 ± 14.7, 39.9 ± 11.7, and 40.5 ± 10.3 BPM, respectively, and did not differ among providers (P = .94). All rates were significantly higher than the recommended rate of 8 to 20 BPM (per Pediatric Advanced Life Support guidelines, varies with patient age) (P < .001). The mean ventilation rate in cases of isolated respiratory arrest was 44.0 ± 13.9 BPM and was not different from the mean BVM ventilation rate in cases of cardiopulmonary arrest (38.9 ± 14.4 BPM; P = .689).

CONCLUSIONS

Hyperventilation occurred in simulated pediatric resuscitation and did not vary according to provider type. Future educational interventions should focus on avoidance of excessive ventilation.

Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis

PURPOSE

Central venous catheterization (CVC) is increasingly taught by simulation. The authors reviewed the literature on the effects of simulation training in CVC on learner and clinical outcomes.

METHOD

The authors searched computerized databases (1950 to May 2010), reference lists, and considered studies with a control group (without simulation education intervention). Two independent assessors reviewed the retrieved citations. Independent data abstraction was performed on study design, study quality score, learner characteristics, sample size, components of interventional curriculum, outcomes assessed, and method of assessment. Learner outcomes included performance measures on simulators, knowledge, and confidence. Patient outcomes included number of needle passes, arterial puncture, pneumothorax, and catheter-related infections.

RESULTS

Twenty studies were identified. Simulation-based education was associated with significant improvements in learner outcomes: performance on simulators (standardized mean difference [SMD] 0.60 [95% CI 0.45 to 0.76]), knowledge (SMD 0.60 [95% CI 0.35 to 0.84]), and confidence (SMD 0.41 [95% CI 0.30 to 0.53] for studies with single-group pretest and posttest design; SMD 0.52 (95% CI 0.23 to 0.81) for studies with nonrandomized, two-group design). Furthermore, simulation-based education was associated with improved patient outcomes, including fewer needle passes (SMD -0.58 [95% CI -0.95 to -0.20]), and pneumothorax (relative risk 0.62 [95% CI 0.40 to 0.97]), for studies with nonrandomized, two-group design. However, simulation-based training was not associated with a significant reduction in risk of either arterial puncture or catheter-related infections.

CONCLUSIONS

Despite some limitations in the literature reviewed, evidence suggests that simulation-based education for CVC provides benefits in learner and select clinical outcomes.

Setting standards for simulation in anesthesia: the role of safety criteria in accreditation standards

PURPOSE

In this article, we describe a critical event which occurred in a simulation centre, and we also review possible safety issues for participants and staff involved in medical simulation training.

PRINCIPAL FINDINGS

The authors report an incident with the potential of harming trainees and staff which occurred during a full-scale simulation. The episode raised the question of training safety in simulation centres. In this instance, the computer program controlling the mannequin enabled a continuous and non-regulated outflow of carbon dioxide which led to an intense reaction in the soda lime canister. The absorbent canister became too hot to be touched (a temperature probe, later placed in the centre of the front canister, measured 53°C). All activities involving the mannequin and anesthesia machine were stopped immediately.

CONCLUSIONS

Simulation in healthcare is a valuable educational tool to train for a variety of clinical encounters in a safe environment without harming a patient. Due to technological progress and the use of authentic equipment recreating near real environments, simulation training has become exceedingly realistic. The Society for Simulation in Healthcare (SSH) has published revised accreditation standards for simulation centres which incorporate training safety sub-criteria to address and manage. By highlighting recommendations of other high-risk industries on this issue, SSH proposes a possible approach to enhance safety in medical simulation.

Advances in simulation for pediatric critical care and emergency medicine

PURPOSE OF REVIEW

Routine integration of simulation into healthcare education and practice has gained momentum. Simulation is particularly important to acute and critical care pediatrics, as it offers alternative methods of training for high-risk and/or lower-frequency events in children. This review will discuss the recent advances in simulation education for pediatric critical care and emergency medicine and assess its potential for future growth through these subspecialties.

RECENT FINDINGS

Research indicates that simulation with a high-fidelity manikin is more realistic than with a simple manikin. Multievent simulation centers, on-site suites and mobile units for in-situ training offer a variety of venues for training. High-fidelity simulation is now used to identify performance gaps, enhance educational curricula and assess core competencies. A landmark study demonstrated improvement in outcomes from in-hospital pediatric cardiopulmonary arrest following the introduction of a pediatric simulation-based mock code program.

SUMMARY

High-fidelity simulation is emerging as a powerful tool for pediatric emergency medicine and critical care education through both individual and team-based training exercises. Programs can be tailored to meet specific institutional needs and budget limitations. As pediatric simulation-based programs evolve, further progress is anticipated in acute and critical care outcomes.

A multirater instrument for the assessment of simulated pediatric crises

BACKGROUND

Few validated instruments exist to measure pediatric code team skills. The goal of this study was to develop an instrument for the assessment of resuscitation competency and self-appraisal using multirater and gap analysis methodologies.

METHODS

Multirater assessment with gap analysis is a robust methodology that enables the measurement of self-appraisal as well as competency, offering faculty the ability to provide enhanced feedback. The Team Performance during Simulated Crises Instrument (TPDSCI) was grounded in the Accreditation Council for Graduate Medical Education competencies. The instrument contains 5 competencies, each assessed by a series of descriptive rubrics. It was piloted during a series of simulation-based interdisciplinary pediatric crisis resource management education sessions. Course faculty assessed participants, who also did self-assessments. Internal consistency and interrater reliability were analyzed using Cronbach α and intraclass correlation (ICC) statistics. Gap analysis results were examined descriptively.

RESULTS

Cronbach α for the instrument was between 0.72 and 0.69. The overall ICC was 0.82. ICC values for the medical knowledge, clinical skills, communication skills, and systems-based practice were between 0.87 and 0.72. The ICC for the professionalism domain was 0.22. Further examination of the professionalism competency revealed a positive skew, 43 simulated sessions (98%) had significant gaps for at least one of the competencies, 38 sessions (86%) had gaps indicating self-overappraisal, and 15 sessions (34%) had gaps indicating self-underappraisal.

CONCLUSIONS

The TPDSCI possesses good measures of internal consistency and interrater reliability with respect to medical knowledge, clinical skills, communication skills, systems-based practice, and overall competence in the context of simulated interdisciplinary pediatric medical crises. Professionalism remains difficult to assess. These results provide an encouraging first step toward instrument validation. Gap analysis reveals disparities between faculty and self-assessments that indicate inadequate participant self-reflection. Identifying self-overappraisal can facilitate focused interventions.

Repetitive pediatric simulation resuscitation training

OBJECTIVE

The objective of the study was to compare the effectiveness of repetitive pediatric simulation (RPS) training (scenario-debriefing-scenario) to standard pediatric simulation (STN) training (scenario-debriefing).

METHODS

Pediatric and emergency medicine residents prospectively participated in simulated pediatric resuscitation training sessions in an in situ simulation room. Residents anonymously reported their knowledge, skills, and confidence after each session. Four learners and 2 faculty preceptors (1 pediatric emergency medicine attending physician and 1 pediatric emergency medicine fellow) participated in each session. Scenarios were performed on a high-fidelity simulator (SimBaby; Laerdal Medical, Stavanger, Norway), and video debriefing was used for all training sessions. Standard pediatric simulation was used in the initial 6 months of the study, whereas RPS was used in the second 6 months of the study.

RESULTS

One hundred fifteen subjects completed simulation sessions during the study period. The RPS group reported higher overall debriefing quality and were more likely to report that the simulation session was an excellent method of teaching. The RPS group reported greater improvement in knowledge and skills than did the STN group. Similar scores were reported for confidence, overall performance, stress levels, and realism of the simulator in both the STN and RPS groups.

CONCLUSIONS

Feedback is a key feature of effective medical simulation. Repetitive pediatric simulation provides learners with a discrete opportunity to apply the knowledge and skills discussed during debriefing in an immediate second simulation session and thereby complete Kolb's experiential learning cycle. In this study, the RPS debriefing format was associated with higher self-reported knowledge and skills. The RPS group reported more positive attitudes toward simulation than the STN group.

Simulation training in graduate medical education: a means of traversing a changed and changing landscape

There have been significant changes in the graduate medical (resident) education in the United States over the last two decades. These changes have been the result of a wide range of societal, governmental, and regulatory alterations which have either directly or indirectly impacted today's physicians-in-training experiences and autonomy, raising concerns about their readiness for independent practice at the completion of training. This article reviews the evolution of these changes and the promise that simulation training holds as one of the keys to ensuring continuing excellence in the training of today's and tomorrow's physicians.