Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy

Simulation-Based Mastery Learning Curriculum Development Workbook

SUMMARY STATEMENT

This Workbook and its Action Plans and Notes aim to equip health professions educators with the information and guidance needed to develop and implement a simulation-based mastery learning curriculum. The Workbook begins with an introductory statement about mastery learning curriculum developers and teachers and also about expected behavior of learners in a mastery context. The Workbook continues with 10 connected sections on simulation-based mastery learning curriculum development: (1) problem identification and needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) education strategies, (5) learner assessment goals and tools, (6) standard setting, (7) curriculum implementation, (8) feedback and debriefing, (9) unexpected collateral effects, and (10) program evaluation. These sections are modeled after the Thomas and Kern (Curriculum Development for Medical Education: A Six-Step Approach. 4th ed. Baltimore: Johns Hopkins University Press; 2022) steps for curriculum development and add several steps needed to incorporate simulation-based mastery learning goals. Curriculum development is an iterative process and each decision impacts preceding and subsequent steps. In addition, steps often change and evolve as a curriculum is developed and revised. Users are encouraged to record and refine their curriculum development plans as they move, back-and-forth, through the Workbook and Action Plans and Notes. References are provided throughout the document to amplify the text and provide detailed examples of the curriculum development steps and procedures. The intended outcome is a simulation-based mastery learning curriculum plan that can be implemented and used to educate learners to a very high standard of achievement.

Investigation of the effectiveness of preoperative intubation simulation using a custom-made simulator for pediatric patients with difficult airway: a pilot study

The purpose of this study is to investigate whether preoperative intubation simulation using custom-made simulator is useful during anesthesia induction for the children who have difficult airway. We included the children under 15 years of age who have difficult airway which had been already known. Prior to the scheduled surgery, CT imaging was performed and a 3D reconstruction of the face from the chest was performed. Then custom-made airway simulator was made. We tried to intubate custom-made simulator of patients preoperatively. We planned how to intubate the patient for anesthesia induction from the result of intubation simulation. The findings of direct laryngoscopy were compared with the findings during intubation. Three patients were included in this study. It took up to 3 weeks to create a simulator, which was difficult due to time constraints to accommodate emergency surgeries. Simulation findings correlated well with findings during anesthesia induction. There were no cases of severe hypotension or hypoxia during induction of anesthesia with the planned intubation method. In conclusion, preoperative intubation simulation using custom-made simulator may be useful for the patients who have difficult airway.

The State of Mastery Learning in Pediatric Graduate Medical Education: A Scoping Review

Objective

The aim of this study was to characterize the state of mastery learning interventions, identify gaps in current approaches, and highlight opportunities to improve the rigor of ML in pediatric graduate medical education (GME) training programs.

Methods

In October 2022, we searched Ovid, PubMed, Scopus, and ERIC. Two reviewers independently screened 165 citations and reviewed the full manuscripts of 20 studies. We developed a modified data abstraction tool based on the Recommendations for Reporting Mastery Education Research in Medicine (ReMERM) guidelines and extracted variables related to mastery learning curricular implementation and design and learner assessment.

Results

Eleven studies of ML approaches within pediatric GME were included in the full review, with over half published after 2020. ML interventions were used to teach both simple and complex tasks, often in heterogeneous learner groups. While deliberate practice and feedback were consistently reported features of ML in pediatrics, opportunities for improvement include clearly defining mastery, conducting learning over multiple sessions, presenting sufficient validity evidence for assessment tools, adhering to rigorous standard setting processes, and reporting psychometric data appropriate for ML.

Conclusion

In pediatric GME, ML approaches are in their infancy. By addressing common shortcomings in the existing literature, future efforts can improve the rigor of ML in pediatric training programs and its impact on learners and patients.

Enhancing Laryngoscopy Mastery: The Impact of Autonomous Practice with Feedback-Providing Simulators

Mastery learning with fixed end points and variable training time leads to more consistent expertise but is difficult to implement. Here we piloted mastery learning of laryngoscopy with independent practice. 35 learners participated in independent mastery learning on a manikin that provides automated performance feedback. A pre- and postpractice assessment of intubation skills was completed. After an average of 21 minutes of open practice, the percentage of subjects that met mastery criteria improved from 24% to 89% (P < .05). Independent intubation practice with manikin feedback facilitated mastery learning, enhanced procedural education, and may impact clinical care.

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study

OBJECTIVE

To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students.

METHODS

33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge's g.

RESULTS

Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20).

CONCLUSION

HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

Necessity of Pretests in Central Venous Catheter Insertion Simulation-Based Mastery Learning: A Randomized Controlled Trial

PURPOSE

Simulation-based mastery learning (SBML) is a rigorous form of competency-based learning. Components of SBML include a pretest, deliberate practice, and a posttest; all learners must meet or exceed a minimum passing standard (MPS) on the posttest before completing training. The authors aimed to explore whether a modified SBML curriculum (without a pretest assessment) was as effective as the standard SBML curriculum (with a pretest assessment).

METHOD

The authors performed a randomized controlled trial of internal medicine residents who participated in an internal jugular central venous catheter insertion SBML curriculum at a tertiary care academic medical center in Chicago, Illinois, from December 2018 through December 2021. Residents were randomly assigned to complete the usual SBML intervention (pretest group) or to complete a modified SBML intervention without a pretest (no pretest group). The authors compared initial posttest performance and training time between groups.

RESULTS

Eighty-nine of 120 eligible residents (74.1%) completed the study: 43 in the pretest group and 46 in the no pretest group. Median (IQR) initial posttest scores were not statistically different between the pretest group (96.6 [93.1-100]) and the no pretest group (96.6 [92.4-100]). However, all 43 residents (100%) in the pretest group reached the MPS at the initial posttest compared with 41 of the 46 (89%) in the no pretest group ( P = .06). Residents in the pretest group required 16.5 hours more faculty and learning time than the no pretest group.

CONCLUSIONS

More residents who completed a pretest reached the MPS at initial posttest. However, incorporating a pretest during the internal jugular central venous catheter SBML curriculum required substantially more learner and faculty time without clear performance benefits.

Trends and Innovations of Simulation for Twenty First Century Medical Education

In the last two decades there has been an enormous growth in the use of clinical simulation. This teaching-learning methodology is currently the main tool used in the training of healthcare professionals. Clinical simulation is in tune with new paradigms in education and is consistent with educational theories that support the use of experiential learning. It promotes the development of psychomotor skills and strengthens executive functions. This pedagogical approach can be applied in many healthcare topics and is particularly relevant in the context of restricted access to clinical settings. This is particularly relevant considering the current crisis caused by the COVID-19 pandemic, or when trying to reduce the frequency of accidents attributed to errors in clinical practice. This mini-review provides an overview of the current literature on healthcare simulation methods, as well as prospects for education and public health benefits. A literature search was conducted in order to find the most current trends and state of the art in medical education simulation. Presently, there are many areas of application for this methodology and new areas are constantly being explored. It is concluded that medical education simulation has a solid theoretical basis and wide application in the training of health professionals at present. In addition, it is consolidated as an unavoidable methodology both in undergraduate curricula and in continuing medical education. A promising scenario for medical education simulation is envisaged in the future, hand in hand with the development of technological advances.

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

Emergency Pediatric Intubations in an Urban Children’s Hospital Before and After Just-in-Time Training for Video Laryngoscopy

Objectives: The use of video laryngoscopy (VL) may augment emergency pediatric intubations outside the operating room (OR). Our objective was to describe the proportion of use and complications with VL before and after implementation of a VL just-in-time training (JITT).

Study design: This study was a retrospective chart review of pediatric intubations performed outside the OR at a single women and children’s hospital from January 2015 to March 2020. Data were collected on patient age, intubation method, operator characteristics, adverse events, number of attempts, condition leading to intubation, and hospital location. Data were separated into pre-JITT (January 1, 2015 to April 31, 2018) and post-JITT (May 1, 2018 to March 1, 2020) periods. Descriptive statistics were used comparing pre- and post-JITT periods for VL use, and the complications of intubations with multiple attempts (IMAs) and intubations with one or more adverse events (AEs).

Results: A total of 231 pediatric patients were intubated during the study period; 154 intubations in the pre-JITT and 77 intubations in the post-JITT periods. Pre- and post-JITT VL use was 17 (11%) and 17 (22%), respectively. With pre-JITT VL, there were four (23%) IMAs and zero (0%) intubation with one or more AE. With post-JITT VL, there were eight (47%) IMAs and one (6%) intubation with one or more AE.

Conclusion: The proportion of emergency pediatric intubations using VL increased after the institution of a JITT. There was no significant change in IMAs and AEs. The infrequency of pediatric intubations makes drawing conclusions regarding the impact on IMAs and AEs challenging. JITT may increase VL use for emergency pediatric intubations outside the OR and may be considered for refresher training, especially during the coronavirus disease 2019 (COVID-19) pandemic.

Declining Procedures in Pediatric Critical Care Medicine Using a National Database

Supplemental Digital Content is available in the text.

Objectives:

To investigate the change in rate of invasive procedures (endotracheal intubation, central venous catheters, arterial catheters, and peripheral inserted central venous catheters) performed in PICUs per admission over time. Secondarily, to investigate the change in type of respiratory support over time.

Design:

Retrospective study of prospectively collected data using the Virtual Pediatric Systems (VPS; LLC, Los Angeles, CA) database.

Setting:

North American PICUs.

Patients:

Patients admitted from January 2009 to December 2017.

Interventions:

None.

Measurements and Main Results:

There were 902,624 admissions from 161 PICUs included in the analysis. Since 2009, there has been a decrease in rate of endotracheal intubations, central venous catheters placed, and arterial catheters placed and an increase in the rate of peripheral inserted central venous catheter insertion per admission over time after controlling for severity of illness and unit level effects. As compared to 2009, the incident rate ratio for 2017 for endotracheal intubation was 0.90 (95% CI, 0.83–0.98; p = 0.017), for central venous line placement 0.69 (0.63–0.74; p < 0.001), for arterial catheter insertion 0.85 (0.79–0.92; p < 0.001), and for peripheral inserted central venous catheter placement 1.14 (1.03–1.26; p = 0.013). Over this time period, in a subgroup with available data, there was a decrease in the rate of invasive mechanical ventilation and an increase in the rate of noninvasive respiratory support (bilevel positive airway pressure/continuous positive airway pressure and high-flow nasal oxygen) per admission.

Conclusions:

Over 9 years across multiple North American PICUs, the rate of endotracheal intubations, central catheter, and arterial catheter insertions per admission has decreased. The use of invasive mechanical ventilation has decreased with an increase in noninvasive respiratory support. These data support efforts to improve exposure to invasive procedures in training and structured systems to evaluate continued competency.