Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention

Caring for deteriorating paediatric patients in the emergency department: A mixed method study

BACKGROUND

Paediatric presentations to emergency departments are common for a range of conditions with varying severity. Children can compensate well and early signs of deterioration may not be obvious. Nurses working in emergency departments (ED) should not only have the knowledge and skill to recognise the unwell child, but also be confident and competent to provide care.

AIM

To explore the self-reported preparedness, confidence and competence of emergency nurses in caring for deteriorating paediatric patients, and to identify how their confidence and competence could be improved.

METHODS

An exploratory sequential mixed methods study with two phases was used. In Phase One, qualitative data were collected via focus group and thematically analysed. The findings from Phase One informed Phase Two survey development, with quantitative data collected and analysed.

RESULTS

Findings from both phases identified that emergency nurses' confidence and competence when caring for deteriorating paediatric patients did not correlate with their level of qualification. In contrast, increased years of experience in caring for this cohort did increase level of confidence. Availability of human resources further impacted nurses' confidence when caring for deteriorating paediatric patients and emergency nurses showed an interest and enthusiasm for further education in caring for the deteriorating paediatric patient.

CONCLUSIONS

Regular exposure to paediatrics was key to nurses having confidence and competence to care for deteriorating patients, irrespective of educational qualifications. A focus on interprofessional insitu simulation could address human resource challenges to enhance skill development.

A Qualitative Exploration of the Impact of a Distressed Family Member on Pediatric Resuscitation Teams

BACKGROUND AND OBJECTIVES

Family presence during resuscitation (FPDR) is commonplace in many hospitals today. Research has supported the positive effects it can have on family members; however, there is little research about how it may affect the resuscitation team's performance, especially in a pediatric population. Our objective was to identify how resuscitation team members perceive and respond to the presence of a distressed family member during a resuscitation.

METHODS

This is a qualitative study in which we examine FPDR-related themes raised by pediatric resuscitation team members after a resuscitation simulation. As part of a team training educational intervention, pediatric resuscitation teams, composed of nurses, respiratory therapists, and resident physicians, participated in a video-recorded simulated event in which they attempted to resuscitate an infant. During the scenario, a confederate actor played the role of a distressed "parent." Video-recorded debriefs occurred immediately after each simulation. Video recordings were transcribed verbatim, and then transcripts were coded and analyzed via thematic analysis to saturation.

RESULTS

Thirteen postevent video debriefs were analyzed. A total of 74 participants took part in these simulations and debriefs. Analysis revealed 15 major and 29 minor themes, which were mapped to 5 factors, namely resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.

CONCLUSIONS

FPDR has an impact on resuscitation team members' responses and influences their adaptive behavior. If not managed well, this may pose potential patient safety concerns. Policy and training of specific teamwork skills are ways in which we can better equip health care providers to effectively manage FPDR.

Simulation-based education to promote confidence in managing clinical aggression at a paediatric hospital

BACKGROUND

An increasing number of incidents involving aggressive behaviour in acute care hospitals are being witnessed worldwide. Acute care hospital staff are often not trained or confident in managing aggression. Competent management of clinical aggression is important to maintain staff and patient safety. Training programmes for acute care staff are infrequently described in the literature and rarely reported for paediatric staff. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management.

AIM AND DESIGN

The aim of this proof of concept study was to develop a simulation-based education session on aggression management for acute care paediatric staff based on best practice principles, to evaluate the acceptability of this training programme and to gain an understanding of the impact of the training on participants' perceived confidence in managing clinical aggression. Two separate simulation exercises were delivered as a 2-h component of a hospital management of clinical aggression (MOCA) training day. Participants completed a written survey immediately prior to, at completion of the simulation-based group training, and at 3-6 months following the simulation training.

FINDINGS

Nine training days were conducted in 2017 for nursing, medical, allied health, education and security staff with a total of 146 participants (83% were acute care nurses). Two thirds (68%) of participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following the simulation training, 80% of all participants reported feeling more confident in managing clinical aggression, 47% reported a 1-point increase in confidence, whilst 33% of participants reported a 2- or 3-point increase. At 3-6 months post-training, 66% of respondents (N = 44) reported continued confidence in managing aggression with 100% of participants stating they would recommend simulation training to colleagues.

CONCLUSIONS

Simulation training is an acceptable method of training and shows promise to improve staff-perceived confidence for managing behavioural emergencies in acute paediatric health care settings. In addition, there were potential enduring positive impacts at 3 months after the study. Whilst resource and time intensive, further research assessing the benefits of utilising simulation training in this setting is warranted in order to minimise staff burn-out and improve outcomes for these very vulnerable patients.

A Novice Guide to Applications of Simulation in the Pediatric Emergency Department

Healthcare systems and health professions education have gone through radical changes in the past decades. These changes have made it imperative to explore innovative and alternative ways of teaching and training. Simulation-based education has emerged as an effective teaching strategy for both learners and practicing health professionals. Simulation is an educational technique that recreates real-life experiences. Learning occurs through participation in these simulation experiences followed by a period of guided debriefing and reflection. Pediatric emergency medicine, by its very nature, can benefit greatly from a well-designed and thoughtfully implemented simulation program. This review outlines situations where simulation may be used for maximum effectiveness in a pediatric emergency department and provides an overview of the basics of debriefing. A thorough description of each identified use of simulation is beyond the scope of this article.

Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration

OBJECTIVES

To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool.

DESIGN

Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours.

SETTING

Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center.

PATIENTS

The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution.

INTERVENTIONS

We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration.

MEASUREMENTS AND MAIN RESULTS

The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis.

CONCLUSIONS

Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review

PROBLEM

Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance.

ELIGIBILITY CRITERIA

Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals.

SAMPLE

Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool.

RESULTS

Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning.

CONCLUSIONS

Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability.

IMPLICATIONS

Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

Standardising communication to improve in-hospital cardiopulmonary resuscitation

AIM

Recommendations for standardised communication to reduce chest compression (CC) pauses are lacking. We aimed to achieve consensus and evaluate feasibility and efficacy using standardised communication during cardiopulmonary resuscitation (CPR) events.

METHODS

Modified Delphi consensus process to design standardised communication elements. Feasibility was pilot tested in 16 simulated CPR scenarios (8 scenarios with physician team leaders and 8 with chest compressors) randomized (1:1) to standardised [INTERVENTION] vs. closed-loop communication [CONTROL]. Adherence and efficacy (duration of CC pauses for defibrillation, intubation, rhythm check) was assessed by audiovisual recording. Mental demand and frustration were assessed by NASA task load index subscales.

RESULTS

Consensus elements for standardised communication included: 1) team preparation 15-30 s before CC interruption, 2) pre-interruption countdown synchronized with last 5 CCs, 3) specific action words for defibrillation, intubation, and interrupting/resuming CCs. Median (Q1,Q3) adherence to standardised phrases was 98% (80%,100%). Efficacy analysis showed a median [Q1,Q3] peri-shock pause of 5.1 s. [4.4; 5.8] vs. 7.5 s. [6.3; 8.8] seconds, p < 0.001, intubation pause of 3.8 s. [3.6; 5.0] vs. 6.9 s. [4.8; 10.1] seconds, p = 0.03, rhythm check pause of 4.2 [3.2,5.7] vs. 8.6 [5.0,10.5] seconds, p < 0.001, median frustration index of 10/100 [5,20] vs. 35/100 [25,50], p < 0.001, and median mental demand load of 55/100 [30,70] vs. 65/100 [50,85], p = 0.41 for standardised vs. closed loop communication.

CONCLUSION

This pilot study demonstrated feasibility of using consensus-based standardised communication that was associated with shorter CC pauses for defibrillation, intubation, and rhythm checks without increasing frustration index or mental demand compared to current best practice, closed loop communication.

Interprofessional simulation in a student community clinic: insights from an educational framework and contact theory

Introduction

Simulation in community care is a relatively understudied area. In this paper, we report a qualitative evaluation of the Simulated Client Interprofessional Education (SCIPE) program in a community clinic for undergraduate health and social care students in a rural setting. We sought to explore the stakeholders’ perceptions and experiences of training for, and conduct of, a simulated client-based activity to support the development of collaborative practice of students. We used an educational framework (presage, process, product–3P) and contact theory to analyse the evaluation data and suggest improvement strategies.

Methods

Data on professional characteristics was collected from facilitators, simulated client and students. Facilitators and simulated clients received training. Written evaluations were collected after training and after the simulated clinics. Purposively sampled facilitators, students and community partner agencies participated in individual semi-structured interviews to gain deeper insights into experiences.

Results

Fourteen clinics involved 5 facilitators, 12 simulated clients and 40 students. Fifteen interviews were conducted. The SCIPE program led to perceived improvements in students’ communication and awareness of interprofessional collaboration. Participation in the program enabled students to experience a holistic approach to client interviewing and development of competency in collaborative goal setting. Further attention to presage and ability of facilitators to build positive contact conditions was identified. Coordination from a central site facilitated exchange and quality assurance for all elements of the program. Scoping of conditions of positive contact enabled a greater understanding of students’ and facilitators’ evaluation of the experience and constraints which would be modifiable for future improvement and sustainability.

Discussion

Although the SCIPE program benefited students, the need for more explicit organisational engagement and support was revealed in interviews. The use of 3P and contact theory was helpful in identifying elements of the program for maintenance and development. Future research could follow students into practice to see if the behaviours are sustained and translated. Strengths included broad stakeholder involvement and immediate feedback. The key limitation was that the activity lacked explicit institutional support, facilitators required further training in briefing and the outcomes largely refer to participants’ perceptions and may not translate to practice.

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA

OBJECTIVES

The goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams.

DESIGN

Observational study.

SETTING

Emergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders.

PARTICIPANTS

Forty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Teams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team.

RESULTS

Across 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88).

CONCLUSIONS

This study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Beyond the United States Medical Licensing Examination Score: Assessing Competence for Entering Residency

Assessments of physician learners during the transition from undergraduate to graduate medical education generate information that may inform their learning and improvement needs, determine readiness to move along the medical education continuum, and predict success in their residency programs. To achieve a constructive transition for the learner, residency program, and patients, high-quality assessments should provide meaningful information regarding applicant characteristics, academic achievement, and competence that lead to a suitable match between the learner and the residency program's culture and focus.The authors discuss alternative assessment models that may correlate with resident physician clinical performance and patient care outcomes. Currently, passing the United States Medical Licensing Examination Step examinations provides one element of reliable assessment data that could inform judgments about a learner's likelihood for success in residency. Yet, learner capabilities in areas beyond those traditionally valued in future physicians, such as life experiences, community engagement, language skills, and leadership attributes, are not afforded the same level of influence when candidate selections are made.While promising new methods of screening and assessment-such as objective structured clinical examinations, holistic assessments, and competency-based assessments-have attracted increased attention in the medical education community, currently they may be expensive, be less psychometrically sound, lack a national comparison group, or be complicated to administer. Future research and experimentation are needed to establish measures that can best meet the needs of programs, faculty, staff, students, and, more importantly, patients.

Can Simulation Based-Team Training Impact Bedside Teamwork in a Pediatric Intensive Care Unit?

Effective teamwork performance is essential to the delivery of high-quality and safe patient care. In this mixed methodological observational cohort study, we evaluated team performance immediately following a real medical crisis in a pediatric intensive care unit (PICU) following implementation of a simulation-based team training (SBTT) program. Comparison of teamwork skills when rated by study observers demonstrated a statistically significant improvement in 12 out of 15 composite teamwork skills during real emergency events following SBTT ( p  < 0.05). Pre- and post-SBTT intervention survey data demonstrated an improvement in the perception of teamwork, most notable in the area of shared mental model and situational awareness following SBTT. Study results suggest that teamwork behaviors and skills acquired during SBTT can translate into improved bedside performance in the PICU.

Low-Fidelity, In-Situ Pediatric Resuscitation Simulation Improves RN Competence and Self-Efficacy

PROBLEM

ED staff lack adequate exposure to critical pediatric patients to develop competence and confidence in resuscitation scenarios. Simulations of various designs have shown success at increasing health care staff performance and self-efficacy.

METHODS

We developed a nurse-led, low-fidelity in situ simulation of a pediatric sepsis scenario. The primary goal was to improve staff adherence to resuscitation guidelines, as measured by the Clinical Performance Tool, a set of checklists designed to measure adherence to Pediatric Advanced Life Support algorithms by multidisciplinary teams during simulations. The secondary goal was to improve staff confidence, measured by the Confidence Scale, a 5-item Likert-type scale that can measure any psychomotor skill.

RESULTS

A total of 43 RNs participated in 12 simulations over a period of 3 months. Mean Clinical Performance score improved by 74%, from 5.3 to 9.2 (P < 0.001). Mean confidence score for RNs improved by 56%, from 2.48 (standard deviation [SD] 0.83) to 3.88 (SD 0.66) (P < 0.001). Several systems issues were identified and addressed by multidisciplinary teams, such as increasing respiratory therapist response to the emergency department and updating of the Broselow cart.

DISCUSSION

In situ low-fidelity simulations led by RNs contributed to significant improvement in adherence to resuscitation guidelines and in staff confidence. The simulation design had minimal impact on staffing and budget and enabled identification and correction of systems issues.

A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training

INTRODUCTION

Medication administration events (MAEs) are a great concern to the healthcare industry, because they are both common and costly. Pediatric patients pose unique challenges to healthcare systems, particularly regarding the safety of medication administration. Our objectives were to improve adherence to best practices, decrease MAEs, and decrease cost related to error reduction rates by implementing a scenario-based simulation training program for frontline nursing staff in the general care units, emergency departments, and intensive care units within our institution.

METHODS

Children's simulation center in conjunction with the medication safety workgroup developed a 2-hour target-specific simulation-based training. This quality initiative focused on implementation of a MAE bundle that included the following three elements: The Five Rights, MedZone, and Independent Double Check. Adherence to the use of bundle elements was monitored via bedside auditing for 18 months after the intervention. This audit was accomplished using an institution-wide MAE reporting system. The 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database and 2014 Children's Hospital Association, Pediatric Health Information System databases were used to estimate cost impact.

RESULTS

A total of 1434 nurses from our intensive care units, emergency departments, and general care inpatient units participated in simulation training. Nursing adherence to the MAE bundle in the 18-month period after simulation increased by 33%, from January 2014 to June 2015. Medication administration event monitoring during the preintervention, intervention, and postintervention periods demonstrated a decrease in error rate from 2.5 events per month to 0.86 events per month This error reduction correlated to an estimated charge savings of $165,000 to $255,000 and a cost impact of $90,000 to $130,000 per year.

CONCLUSIONS

Target-specific simulation-based training on a large scale has improved adherence with best practice guidelines and has led to a significant reduction in MAEs.

Simulation-Based Team Training Improves Team Performance among Pediatric Intensive Care Unit Staff

Simulation training fosters collaborative learning and improves communication among interdisciplinary teams. In this prospective observational cohort study, we evaluated the impact of interdisciplinary simulation-based team training (SBTT) on immediate learning of team performance behaviors. In a 3-month period, 30 simulation sessions were conducted and 165 staff members, including physicians, nurses, and respiratory therapists, were trained. Regression analysis showed a statistically significant improvement in team performance ( p  < 0.0001). Study results demonstrate that SBTT is effective in immediate acquisition of optimal team performance behaviors by multidisciplinary pediatric intensive care unit staff, including physicians with higher level subspecialty training in the simulation environment.

The effects of team-training in intensive care medicine: A narrative review

PURPOSE

Research into team-training within healthcare is growing exponentially. We aim to evaluate the effects of team-training within intensive care medicine (ICM) through a review of the literature and a narrative synthesis of the results.

MATERIALS AND METHODS

A search of OVID Medline, EMBASE and Scopus databases was undertaken. Keywords and MESH headings included were "team-based learning", "team-training", "interdisciplinary training", "intensive care medicine", "ICU", "intensive care unit", "critical care teams" and "critical care". Relevant papers were then analysed for a narrative synthesis.

RESULTS

Our search identified 187 articles. A total of 27 papers were analysed and their outcomes were evaluated based on the Kirkpatrick four step model of evaluation.

CONCLUSIONS

Team-training has been studied in multiple ICU team types, with crew resource management (CRM) and TeamSTEPPS curricula commonly used to support teaching via simulation. Clinical skills taught have included ALS provision, ECMO initiation, advanced airway management, sepsis management and trauma response skills. Team-training in ICU is well received by staff, facilitates clinical learning, and can positively alter staff behaviors. Few clinical outcomes have been demonstrated and the duration of the behavioral effects is unclear.

Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: A randomized simulation-based clinical trial

AIM

To determine if integrating a trained CPR Coach into resuscitation teams can improve CPR quality during simulated pediatric cardiopulmonary arrest (CPA).

METHODS

We conducted a multicenter, prospective, randomized trial. An 18-minute simulated CPA scenario was run for resuscitation teams comprised of CPR-certified professionals from four International Network for Simulation-based Pediatric Innovation, Research & Education (INSPIRE) institutions. Forty teams (200 participants) were randomized to having a trained CPR Coach vs. no CPR Coach. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. All teams utilized CPR feedback technology. We report the proportion of overall excellent CPR, proportion of chest compressions (CC) with depth 50-60 mm, the proportion of CC with rate 100-120 per minute, CC fraction, and pre-, post-, and peri-shock pause duration.

RESULTS

CPR coached teams compared with teams without a CPR Coach resulted in an absolute improvements in overall excellent CPR by 31.8% (95% CI, 17.7, 35.9; p < 0.001), mean CC depth compliance by 31.5% (15.7, 47.4; p < 0.001), mean CC depth by 4.6 mm (1.6, 7.5; p < 0.001), mean CC fraction by 5.4% (0.2, 10.6; p = 0.04), and mean pre-, post- and peri-shock pause duration by -2.7 s (-5.1, -0.4; p = 0.02), -1.0 s (-1.8, -0.2; p = 0.01); and -3.8 (-6.6, -1.0; p = 0.008), respectively. Changes in mean CC rate compliance and mean CC rate were not statistically significant.

CONCLUSIONS

In the presence of CPR feedback technology, the integration of a trained CPR coach into resuscitation teams enhances CPRquality metrics associated with improved survival outcomes from pediatric cardiac arrest.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study

BACKGROUND

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.

OBJECTIVES

To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.

METHODS

Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.

RESULTS

Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).

CONCLUSIONS

In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

Impact of adult advanced cardiac life support course participation on patient outcomes-A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to evaluate the impact of the prior participation of one or more members of the adult resuscitation team in an accredited advanced life support course on patient outcomes (return of spontaneous circulation, survival to discharge, survival to 30 days, and survival to 1 year).

METHODS

A systematic search of Medline, CINAHL, Embase, ERIC, and Cochrane databases was conducted through 6 March 2018. We included randomised and observational studies in any language. Reviewers independently extracted data on study design and outcomes. The GRADE approach was used to evaluate the overall quality of evidence for each outcome.

RESULTS

Nine hundred and ninety-two articles were identified of which eight observational studies were included. No randomised controlled trials were identified. Meta-analysis showed an association between participation of healthcare personnel in an advanced life support course and return of spontaneous circulation [odds ratio (OR) 1.64; 95% CI 1.12-2.41, risk difference (RD) 0.10 (95% CI 0.03-0.17)]. Life support training showed a significant absolute effect on patient survival to discharge [RD 0.10, 95% CI 0.01-0.18], but non-significant relative effect [OR 2.12; 95% CI 0.98-4.57]. Data from one study showed an association with survival to 30 days [OR 7.15; 95% CI 1.61-31.69, RD 0.18 (95% CI 0.08-0.27)].

CONCLUSION

The inference of this review is that the advanced life support courses have a positive impact upon return of spontaneous circulation and survival to hospital discharge. The data also implies a positive impact upon survival to 30 days of adult cardiac arrest patients.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative

BACKGROUND

The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA.

METHODS

Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.

RESULTS

Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).

CONCLUSION

Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

A taxonomy and rating system to measure situation awareness in resuscitation teams

Team SA involves a common perspective between two or more individuals regarding current environmental events, their meaning, and projected future status. Team SA has been theorized to be important for resuscitation team effectiveness. Accordingly, multidimensional frameworks of observable behaviors relevant to resuscitation teams are needed to understand more deeply the nature of team SA, its implications for team effectiveness, and whether it can be trained. A seven-dimension team resuscitation SA framework was developed following a literature review and consensus process using a modified Delphi approach with a group of content experts. We applied a pre-post design within a day-long team training program involving four video-recorded simulated resuscitation events and 42 teams across Canada. The first and fourth events represented “pre” and “post” training events, respectively. Teams were scored on SA five times within each 15-minute event. Distractions were introduced to investigate whether SA scores would be affected. The current study provides initial construct validity evidence for a new measure of SA and explicates SA's role in resuscitation teams.

Interprofessional practice in different patient care settings: A qualitative exploration

Increasing interprofessional practice is seen as a path to improved quality, decreased cost, and enhanced patient experience. However, little is known about how context shapes interprofessional work and how interventions should be crafted to account for a specific setting of interprofessional practice. To better understand, how the work of interprofessional practice differs across patient care settings we sought to understand the social processes found in varying work contexts to better understand how care is provided. A case study design was used in this study to yield a picture of patient care across three different settings. Qualitative analysis of teams from three healthcare settings (rehabilitation, acute care, and code team) was conducted, through the use of ten in-depth semi-structured interviews. Interview data from each participant were analyzed via an inductive content analysis approach based upon theories of work and teams from organisational science, a framework for interprofessional practice, and competencies for interprofessional education. The work processes of interprofessional practice varied across settings. Information exchange was more physician-centric and decision-making was more physician dominant in the non-rehabilitation settings. Work was described as concurrent only for the code team. Goal setting varied by setting and interpersonal relationships were only mentioned as important in the rehabilitation setting. The differences observed across settings identify some insights into how context shapes the process of interprofessional collaboration and some research questions that need further study.

Workload of Team Leaders and Team Members During a Simulated Sepsis Scenario

OBJECTIVES

Crisis resource management principles dictate appropriate distribution of mental and/or physical workload so as not to overwhelm any one team member. Workload during pediatric emergencies is not well studied. The National Aeronautics and Space Administration-Task Load Index is a multidimensional tool designed to assess workload validated in multiple settings. Low workload is defined as less than 40, moderate 40-60, and greater than 60 signify high workloads. Our hypothesis is that workload among both team leaders and team members is moderate to high during a simulated pediatric sepsis scenario and that team leaders would have a higher workload than team members.

DESIGN

Multicenter observational study.

SETTING

Nine pediatric simulation centers (five United States, three Canada, and one United Kingdom).

PATIENTS

Team leaders and team members during a 12-minute pediatric sepsis scenario.

INTERVENTIONS

National Aeronautics and Space Administration-Task Load Index.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-seven teams were recruited from nine sites. One hundred twenty-seven team leaders and 253 team members completed the National Aeronautics and Space Administration-Task Load Index. Team leader had significantly higher overall workload than team member (51 ± 11 vs 44 ± 13; p < 0.01). Team leader had higher workloads in all subcategories except in performance where the values were equal and in physical demand where team members were higher than team leaders (29 ± 22 vs 18 ± 16; p < 0.01). The highest category for each group was mental 73 ± 13 for team leader and 60 ± 20 for team member. For team leader, two categories, mental (73 ± 17) and effort (66 ± 16), were high workload, most domains for team member were moderate workload levels.

CONCLUSIONS

Team leader and team member are under moderate workloads during a pediatric sepsis scenario with team leader under high workloads (> 60) in the mental demand and effort subscales. Team leader average significantly higher workloads. Consideration of decreasing team leader responsibilities may improve team workload distribution.