Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study

Eye tracking during a simulated start of shift safety check: An observational analysis of gaze behavior of critical care nurses

Background

The handover and associated shift start checks by nurses of critical care patients are complex and prone to errors. However, which aspects lead to errors remains unknown. Fewer errors might occur in a structured approach. We hypothesized that specific gaze behavior during handover and shift start safety check correlates with error recognition.

Methods

In our observational eye tracking study, we analyzed gaze behavior of critical care nurses during handover and shift start safety check in a simulation room with built-in errors. Four areas of interest (AOI) were pre-defined (patient, respirator, prescriptions, monitor). The primary outcome were different gaze metrics (time to first fixation, revisits, first visual intake duration, average visual intake duration, dwell time) on AOIs. Parameters were analyzed by taking all errors in account, and by dividing them into minor and critical.

Results

Forty-three participants were included. All participants committed at least a minor error (n = 43, 100%), at least one critical error occurred in 29 participants (67%). Taking all errors into account, longer time to first fixation and more revisits were associated with an increased risk of missing errors (Time to First Fixation: OR 1.099 (95% CI 1.023-1.191, p = 0.0002), Revisits: OR 1.080 (95% CI 1.025-1.143, p = 0.0055)).

Conclusion

Error detection during shift start safety check was associated with distinct gaze behavior. Nurses who recognized more errors had a shorter time to first fixation and less revisits. These gaze characteristics might correspond to a more structured approach. Further research is necessary, for example by implementing a checklist, to reduce errors in the future and improve patient safety.

Simulation based education in paediatric resuscitation

There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology - reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully.

Why Simulation Matters: A Systematic Review on Medical Errors Occurring During Simulated Health Care

BACKGROUND

Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature.

OBJECTIVE

The aim of the study is to identify and categorize the type and frequency of reported medical errors in healthcare simulation.

METHODS

Systematic review using search engines, PubMed/MEDLINE, CINAHL, and SCOPUS from 2000 to 2020, using the terms "healthcare simulation" AND "medical error." Inclusion was based on reported primary research of medical errors occurring during simulated health care. Reported errors were classified as errors of commission, omission, systems related, or communication related.

RESULTS

Of the 1105 articles screened, only 20 articles met inclusion criteria. Errors of commission were the most reported (17/20), followed by systems-related errors (13/20), and errors of omission (12/20). Only 7 articles reported errors attributed to communication. Authors in 16 articles reported more than one type of error.

CONCLUSIONS

Simulationists and patient safety advocates must continually identify systems-related errors and training deficits that can lead to inaction, improper action, and poor communication. Recent dialogs in the simulation community have also underscored the potential benefits of developing a registry of errors across simulation centers, with a goal of aggregating, analyzing, and disseminating insights from various simulation exercises.

Taking the Pulse of the Current State of Simulation

Simulation in health-care professions has grown in the last few decades. We provide an overview of the history of simulation in other fields, the trajectory of simulation in health professions education, and research in medical education, including the learning theories and tools to assess and evaluate simulation programs. We also propose future directions for simulation and research in health professions education.

A Decade Later-Progress and Next Steps for Pediatric Simulation Research

SUMMARY STATEMENT

A decade ago, at the time of formation of the International Network for Pediatric Simulation-based Innovation, Research, and Education, the group embarked on a consensus building exercise. The goal was to forecast the facilitators and barriers to growth and maturity of science in the field of pediatric simulation-based research. This exercise produced 6 domains critical to progress in the field: (1) prioritization, (2) research methodology and outcomes, (3) academic collaboration, (4) integration/implementation/sustainability, (5) technology, and (6) resources/support/advocacy. This article reflects on and summarizes a decade of progress in the field of pediatric simulation research and suggests next steps in each domain as we look forward, including lessons learned by our collaborative grass roots network that can be used to accelerate research efforts in other domains within healthcare simulation science.

Be Prepared: A Pediatric Simulation Center's Early Pandemic Contributions

INTRODUCTION

The COVID-19 pandemic forced healthcare institutions to rapidly adapt practices for patient care, staff safety, and resource management. We evaluated contributions of the simulation center in a freestanding children's hospital during the early stages of the pandemic.

METHODS

We reviewed our simulation center's activity for education-based and system-focused simulation for 2 consecutive academic years (AY19: 2018-2019 and AY20: 2019-2020). We used statistical control charts and χ 2 analyses to assess the impact of the pandemic on simulation activity as well as outputs of system-focused simulation during the first wave of the pandemic (March-June 2020) using the system failure mode taxonomy and required level of resolution.

RESULTS

A total of 1983 event counts were reported. Total counts were similar between years (994 in AY19 and 989 in AY20). System-focused simulation was more prevalent in AY20 compared with AY19 (8% vs. 2% of total simulation activity, P < 0.001), mainly driven by COVID-19-related simulation events. COVID-19-related simulation occurred across the institution, identified system failure modes in all categories except culture, and was more likely to identify macro-level issues than non-COVID-19-related simulation (64% vs. 44%, P = 0.027).

CONCLUSIONS

Our simulation center pivoted to deliver substantial system-focused simulation across the hospital during the first wave of the COVID-19 pandemic. Our experience suggests that simulation centers are essential resources in achieving safe and effective hospital-wide improvement.

Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events

INTRODUCTION

Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation.

METHODS

Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached.

RESULTS

Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions.

CONCLUSIONS

Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.

Simulation-based assessment of care for infant cardiogenic shock in the emergency department

BACKGROUND

Congenital heart disease (CHD) is the leading cause of infant deaths associated with birth defects. Neonates with undiagnosed CHD often present to general emergency departments (GEDs) for initial resuscitation that are less prepared than paediatric centres, resulting in disparities in the quality of care. Neonates with undiagnosed CHD represent a challenge; thus, it is necessary for GEDs to be prepared for this population.

AIM

To evaluate the process of resuscitative care provided to a neonate in cardiogenic shock due to CHD in the GEDs in a simulated setting and to describe the impact of teams and GED variables on the process of care.

METHODS

This is a prospective simulation-based assessment of the process of care provided to a neonate with coarctation of the aorta in cardiogenic shock. Simulation sessions were conducted at participating GEDs utilizing each GED's interdisciplinary team and resources. The primary outcome was adherence to best practice, as measured by a 15-item overall composite adherence score (CAS). In addition, we stratified the overall CAS into CHD-critical items and the general resuscitation items CAS. The secondary outcome was the impact of the team's and GED's characteristics on the scores.

FINDINGS

This study enrolled 32 teams from 12 GEDs. Among 161 participants, 103 (63.97%) were registered nurses, 33 (20.50%) were physicians, 17 (10.56%) were respiratory therapists, and 8 (4.97%) were other medical professionals. The overall median CAS was 84, with the CHD-critical items having a median CAS of 34.5. The most underperformed tasks are checking pulses on the upper and lower extremities (44%), obtaining blood pressure in the upper and lower extremities (25%), and administering prostaglandin E1 (22%).

CONCLUSIONS

Using in situ simulation in a set of GEDs, we revealed gaps in the resuscitation care of neonates with CHD in cardiogenic shock.

RELEVANCE TO CLINICAL PRACTICE

These findings highlight the importance of targeted improvement programs for high-stakes illnesses in GED.

Anaphylaxis viewed by experts: unmet needs

PURPOSE OF REVIEW

The purpose of the review is to identify unmet needs in the management of anaphylaxis, covering aspects such as epidemiology, diagnosis, treatment and prevention.

RECENT FINDINGS

Redefinition of clinical diagnostic criteria may allow a better identification of anaphylaxis. International diagnostic coding system improvement will be major step for future policies and epidemiological studies. Digital health can aid in managing anaphylaxis.

SUMMARY

Anaphylaxis is a medical emergency; current data show that frequently identification of the reaction, acute and long-term management, are not optimal. Therefore, there is a need to implement strategies to improve the situation. This review has identified unmet needs in anaphylaxis regarding aspects such as epidemiology, severity scoring, definition and diagnostic criteria, anaphylaxis in infants and toddlers, cofactors, biomarkers, long-term management, undertreatment and availability of epinephrine autoinjectors. Strategies focused on education, legislation, digital health and research are proposed.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Update on food allergy

Food allergy is a major public health issue with growing prevalence in the urbanized world and significant impact on the lives of allergic patients and their families. Research into the risk factors that have contributed to this increase and their underlying immune mechanisms could lead us to definitive ways for treatment and prevention of food allergy. For the time being, introduction of peanut and other allergenic foods in the diet at the time of weaning seems to be an effective way to prevent the development of food allergy. Improved diagnosis and appropriate management and support of food allergic patients are central to patient care with food immunotherapy and biologics making the transition to clinical practice. With the new available treatments, it is becoming increasingly important to include patients' and family preferences to provide a management plan tailored to their needs.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Adhering to Social Distancing Rules Using a "Split Patient" Model With Rapid Cycle Deliberate Practice in Pediatric High-Fidelity Simulations

The coronavirus disease 2019 (COVID-19) pandemic has required simulation-based medical education to adapt to physical distancing regulations in order to protect learners and facilitators. The "split patient" model allows for physical distancing of learners in pediatric high-fidelity simulations. This model was able to be used with the Rapid Cycle Deliberate Practice to teach pediatric residents basic and advanced life support skills and the principles of Crisis Resource Management.

Simulation in Pediatrics: A Learning Lab for Education, Quality Improvement, and Patient Safety

Simulation-based medical education is an experiential modality that has evolved over the last 60 years, amassing evidence as an efficacious tool for skill acquisition and care improvement. We review the underlying theory, core defining principles, and applications of medical simulation broadly and in pediatrics in hopes that it can be accessible to every pediatric clinician regardless of practice environment and resources. Any situation where there is risk of harm to a patient or clinician can be simulated for practice, reflection, and re-practice. Whether preparing for clinic-based emergencies, new hospital units, or new daily workflows, simulation is valuable to novice and master clinicians for individual and team care enhancement. [Pediatr Ann. 2021;50(1):e13-e18.].

Incorporating Simulation Into Your Plan-Do-Study-Act Cycle

Plan-Do-Study-Act (PDSA) cycles are nearly universal within various quality improvement (QI) methodologies as a way of testing change prior to implementation. Simulation in health care has traditionally been used to improve teaching, enhance learning, and assess performance; however, it can also be powerful when used in the realm of QI work. Simulation is incredibly versatile and can be incorporated into the different phases of a PDSA cycle. Investigators often encounter situations in which a test of change in the real clinical environment may not be ideal; however, simulation is not considered because many practitioners are not familiar with its use. This article reviews the basics of PDSA cycles and provides examples of how simulation can be used for testing in each phase. Included are clear indications to help practitioners decide when simulation is appropriate to use and how to apply it to a variety of different QI projects. [Pediatr Ann. 2021;50(1):e25-e31.].

What is new in anaphylaxis?

Available information suggests that anaphylaxis must be promptly recognized keeping in mind the airway patency, breathing (ventilation and respiration), circulation and mental status and treated. The first treatment is adrenaline. After successful treatment of an anaphylactic episode, attention must be paid to the prevention of early recurrences (biphasic anaphylaxis) and assessment of causes. Children should not be discharged before prescribing self-injectable adrenaline and explain how and under what circumstances it must be injected, An action plan must be communicated to their communities. Inform the school about potential reactions, how to prevent them and avoidance measures.

Recent Advances in Simulation for Pediatric Critical Care Medicine

PURPOSE OF REVIEW

This review highlights the emerging fields of simulation research by tying innovation into principles of learning and process improvement.

RECENT FINDINGS

Advances have been made in both educational simulation and simulation for quality improvement, allowing this versatile modality to be more broadly applied to healthcare and systems.

SUMMARY

Simulation in pediatric critical care medicine continues to evolve. Although the majority of simulation is focused on learner education, emerging research has broadened to focus on patient- and system-centered outcomes, leading to improvement in the quality of care delivered in the ICU.