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

Management of Paediatric Cardiac Arrest due to Shockable Rhythm-A Simulation-Based Study at Children's Hospitals in a German Federal State

(1) Background: To improve the quality of emergency care for children, the Hessian Ministry for Social Affairs and Integration offered paediatric simulation-based training (SBT) for all children's hospitals in Hesse. We investigated the quality of paediatric life support (PLS) in simulated paediatric resuscitations before and after SBT. (2) Methods: In 2017, a standardised, high-fidelity, two-day in-house SBT was conducted in 11 children's hospitals. Before and after SBT, interprofessional teams participated in two study scenarios (PRE and POST) that followed the same clinical course of apnoea and cardiac arrest with a shockable rhythm. The quality of PLS was assessed using a performance evaluation checklist. (3) Results: 179 nurses and physicians participated, forming 47 PRE and 46 POST interprofessional teams. Ventilation was always initiated. Before SBT, chest compressions (CC) were initiated by 87%, and defibrillation by 60% of teams. After SBT, all teams initiated CC (p = 0.012), and 80% defibrillated the patient (p = 0.028). The time to initiate CC decreased significantly (PRE 123 ± 11 s, POST 76 ± 85 s, p = 0.030). (4) Conclusions: The quality of PLS in simulated paediatric cardiac arrests with shockable rhythm was poor in Hessian children's hospitals and improved significantly after SBT. To improve children's outcomes, SBT should be mandatory for paediatric staff and concentrate on the management of shockable rhythms.

Development and Validation of a Novel Ultra-Compact and Cost-Effective Device for Basic Hands-On CPR Training: A Randomized, Sham-Controlled, Blinded Trial

To examine the performance of a novel low-cost, ultra-compact, and attractive auditory feedback device for training laypeople in external chest compressions (ECCs), we conducted a quasi-experimental cross-sectional study from September to November 2021 at the Faculty of Nursing of Albacete, University of Castille-La Mancha, Spain. The ECC sequence was performed in the laboratory with the new device for basic hands-on CPR training. Results: One hundred college students were included in this study. The compression rate/min with the new device was 97.6, and the adequate %ECC was 52.4. According to the status of body mass index (BMI) and muscle strength of the upper limbs in the bivariate analysis, it was observed that the new device discriminated between those who performed correct ECCs according to their BMI and muscle strength and those who did not, which led to significantly influenced results in terms of the percentage of ECCs with correct depth. Conclusions: The new ultra-compact auditory feedback device "Salvando a Llanetes^®" demonstrated utility for teaching and learning ECCs in basic CPR. We can affirm that the analyzed device is an adequate, safe and economical method for teaching "CPR Hands-Only™" to the general population.

A Mixed Methods Study of Senior Medical Student Help Calling in an Individual, Acute Care Simulation Experience

INTRODUCTION

The ability to appropriately seek help is a key skill for medical students transitioning to residency. We designed a simulation activity for senior medical students and became interested in studying help calling behaviors and attitudes.

METHODS

We collected quantitative data regarding help calling for 2 simulation cases and qualitative data using a survey. We undertook a structured thematic analysis based on grounded theory methodology. We identified and compared groups who did and did not call for help.

RESULTS

One hundred thirty-four students participated and 122 (91%) completed an evaluation. More students called for help without prompting in the second case (34/134, 25% in first case; 110/134, 82% in second case, P < 0.001). Most students did not call for help in the first case but called in the second case (81, 60%). Our qualitative analysis identified 5 themes: (1) students seek to avoid shame and burdening their team, (2) prior institutional simulation and testing experience may imprint help calling behaviors, (3) students view help calling primarily through an individual lens, (4) students overestimate the complexity of the help calling process, and (5) the simulation environment and intentional experimentation make it difficult to observe natural behavior. When compared with help callers, more non-help callers had phrases coded as "perception of expectations" (37% vs. 10%, P = 0.03).

CONCLUSIONS

Learners participating in simulation exercises designed to promote help-calling behaviors face training-based barriers related to shame and the desire for autonomy and simulation-based challenges related to assessment.

COVID-19 and the Digitalisation of Cardiovascular Training and Education-A Review of Guiding Themes for Equitable and Effective Post-graduate Telelearning

The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact leading to novel adaptations in post-graduate medical education for cardiovascular and general internal medicine. Whilst the results of initial community COVID-19 vaccination are awaited, continuation of multimodality teaching and training that incorporates telelearning will have enduring benefit to post-graduate education and will place educational establishments in good stead to nimbly respond in future pandemic-related public health emergencies. With the rise in innovative virtual learning solutions, medical educators will have to leverage technology to develop electronic educational materials and virtual courses that facilitate adult learning. Technology-enabled virtual learning is thus a timely progression of hybrid classroom initiatives that are already adopted to varying degrees, with a need for faculty to serve as subject matter experts, to host and moderate online discussions, and to provide feedback and overall mentorship. As an extension from existing efforts, simulation-based teaching (SBT) and learning and the use of mixed reality technology should also form a greater core in the cardiovascular medicine curriculum. We highlight five foundational themes for building a successful e-learning model in cardiovascular and general post-graduate medical training: (1) digital solutions and associated infrastructure; (2) equity in access; (3) participant engagement; (4) diversity and inclusion; and (5) patient confidentiality and governance framework. With digitalisation impacting our everyday lives and now how we teach and train in medicine, these five guiding principles provide a cognitive scaffold for careful consideration of the required ecosystem in which cardiovascular and general post-graduate medical education can effectively operate. With due consideration of various e-learning options and associated infrastructure needs; and adoption of strategies for participant engagement under sound and just governance, virtual training in medicine can be effective, inclusive and equitable through the COVID-19 era and beyond.

Excellence in Communication and Emergency Leadership (ExCEL): Pediatric First 5 Minutes Workshop for Residents

INTRODUCTION

In-hospital pediatric cardiopulmonary arrest is associated with high morbidity and mortality, and appropriate initial management has been associated with improved clinical outcomes. Despite current training, pediatric residents often do not feel confident in their ability to deliver this initial management. This workshop focused on the initial management of critically ill pediatric patients and performance of high-quality CPR.

METHODS

This hands-on workshop utilized skill stations with low- and medium-fidelity simulators to instruct learners on initial management during the first 5 minutes of a code, including high-quality CPR. It was designed for residents across all levels of training who care for pediatric patients (including pediatrics, medicine-pediatrics, pediatrics, psychiatry, and child psychiatry, family medicine, and emergency medicine residents) and can be adapted for different session durations and group sizes.

RESULTS

This workshop was conducted at two separate institutions with a total of 18 resident participants. Participants strongly agreed that this workshop was relevant and effective in teaching the initial assessment and management of the critical pediatric patient, including how to best perform high-quality CPR. Residents further reported high levels of confidence in initially assessing and managing a critically ill patient, describing the markers of high-quality CPR, and performing high-quality CPR.

DISCUSSION

This workshop provided residents with additional instruction and practice in the initial management of critically ill pediatric patients in cardiopulmonary arrest. The structure and timeline of this curriculum can be adapted to the needs of the individual institution's program and the number of workshop participants.

Novel modified Peyton's approach for knowledge retention on newborn life support training in medical students

AIM

We sought to improve retention of neonatal resuscitation skills by modifying step 3 through additional functional verbalisation in Peyton's four-step approach (P4S).

METHODS

Newborn life support (NLS) training was performed in a simulation-based setting. In contrast to the traditional approach, students taught with the modified approach were requested to explain every step of their performance in Peyton's step 3. A total of 123 students were allocated into both experimental groups. Students were then assessed by megacode on day four (initial assessment) and 6 months (follow-up assessment).

RESULTS

Both groups showed similar scorings in the initial, follow-up assessment and in mean change. On initial megacode, time to start with initial inflation and post-resuscitation care was significantly faster in the control group. All showed a significant loss of performance irrespective of modification in step 3 in the follow-up assessment. Only time until start with post-resuscitation care shows a significant group difference in mean change between initial and follow-up with increasing time in the control and decreasing time span in intervention group.

CONCLUSION

Both methods showed equal levels of knowledge acquisition and long-term decline in NLS performances. Verbalisation in step 3 influenced speed of applied NLS performance.

The Impact of Mock Code Simulation on the Resuscitation Practice and Patient Outcome for Children With Cardiopulmonary Arrest

Background Cardiopulmonary arrest is an uncommon event in pediatric patients. Additionally, physicians-in-training see far fewer cardiopulmonary arrest events. Therefore, they have limited confidence in their resuscitation skills. Mock code training with active participation and debriefing may be an effective tool to fill this gap in experience. The aims of the study were to assess the impact of a mock code simulation program on patient outcome for children with cardiopulmonary arrest in a tertiary pediatric academic center and provide evidence that code simulations can improve the quality of cardiopulmonary resuscitation (CPR). Methods This was a retrospective cohort study conducted in a tertiary academic center. This study had two phases: Phase 1 before the mock code simulation program began (pre-intervention) and Phase 2 after the mock code program began (post-intervention). The data were collected from pediatric patients with cardiopulmonary arrest during the study period who met the inclusion criteria, and variables included the survival rate at hospital discharge, CPR initiation time, time to the first dose of epinephrine, and the adherence rate to American Heart Association (AHA) guidelines. Results A total of 13 patients in the pre-intervention period and 19 patients in the post-intervention period were included. The results showed a significant improvement in team performance represented by a decrease in CPR initiation time post-intervention and improvement in AHA adherence; however, the results did not show a significant difference in the survival rate or mortality within 28 days of the cardiopulmonary arrest event between the pre- and post-intervention groups. Conclusions Mock code simulation was a helpful tool to enhance team performance and improve the quality of cardiac resuscitation and cardiac arrest recognition, while its impact on the survival rate was not significant in our study.

The Impact of a Tablet App on Adherence to American Heart Association Guidelines During Simulated Pediatric Cardiopulmonary Resuscitation: Randomized Controlled Trial

Background

Evidence-based best practices are the cornerstone to guide optimal cardiopulmonary arrest resuscitation care. Adherence to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite advances in resuscitation science and survival improvement over the last decades, only approximately 38% of children survive to hospital discharge after in-hospital cardiac arrest and only 6%-20% after out-of-hospital cardiac arrest.

Objective

We investigated whether a mobile app developed as a guide to support and drive CPR providers in real time through interactive pediatric advanced life support (PALS) algorithms would increase adherence to AHA guidelines and reduce the time to initiation of critical life-saving maneuvers compared to the use of PALS pocket reference cards.

Methods

This study was a randomized controlled trial conducted during a simulation-based pediatric cardiac arrest scenario caused by pulseless ventricular tachycardia (pVT). A total of 26 pediatric residents were randomized into two groups. The primary outcome was the elapsed time in seconds in each allocation group from the onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, including the time intervals between defibrillation attempts and drug doses, shock doses, and the number of shocks. All outcomes were assessed for deviation from AHA guidelines.

Results

Mean time to the first defibrillation attempt (121.4 sec, 95% CI 105.3-137.5) was significantly reduced among residents using the app compared to those using PALS pocket cards (211.5 sec, 95% CI 162.5-260.6, P<.001). With the app, 11 out of 13 (85%) residents initiated chest compressions within 60 seconds from the onset of pVT and 12 out of 13 (92%) successfully defibrillated within 180 seconds. Time to all other defibrillation attempts was reduced with the app. Adherence to the 2018 AHA pVT algorithm improved by approximately 70% (P=.001) when using the app following all CPR sequences of action in a stepwise fashion until return of spontaneous circulation. The pVT rhythm was recognized correctly in 51 out of 52 (98%) opportunities among residents using the app compared to only 19 out of 52 (37%) among those using PALS cards (P<.001). Time to epinephrine injection was similar. Among a total of 78 opportunities, incorrect shock or drug doses occurred in 14% (11/78) of cases among those using the cards. These errors were reduced to 1% (1/78, P=.005) when using the app.

Conclusions

Use of the mobile app was associated with a shorter time to first and subsequent defibrillation attempts, fewer medication and defibrillation dose errors, and improved adherence to AHA recommendations compared with the use of PALS pocket cards.

Rapid cycle deliberate practice vs. traditional simulation in a resource-limited setting

BACKGROUND

We sought to develop a low-fidelity simulation-based curriculum for pediatric residents in Rwanda utilizing either rapid cycle deliberate practice (RCDP) or traditional debriefing, and to determine whether RCDP leads to greater improvement in simulation-based performance and in resident confidence compared with traditional debriefing.

METHODS

Pediatric residents at the Centre Hospitalier Universitaire de Kigali (CHUK) were randomly assigned to RCDP or traditional simulation and completed a 6 month-long simulation-based curriculum designed to improve pediatric resuscitation skills. Pre- and post- performance was assessed using a modified version of the Simulation Team Assessment Tool (STAT). Each video-taped simulation was reviewed by two investigators and inter-rater reliability was assessed. Self-confidence in resuscitation, pre- and post-simulation, was assessed by Likert scale survey. Analyses were conducted using parametric and non-parametric testing, ANCOVA and intra-class correlation coefficients (ICC).

RESULTS

There was a 21% increase in pre- to post-test performance in both groups (p < 0.001), but no difference between groups (mean difference - 0.003%; p 0.94). Inter-rater reliability was exceptional with both pre and post ICCs ≥0.95 (p < 0.001). Overall, self-confidence scores improved from pre to post (24.0 vs. 30.0 respectively, p < 0.001), however, the there was no difference between the RCDP and traditional groups.

CONCLUSIONS

Completion of a six-month low-fidelity simulation-based curriculum for pediatric residents in Rwanda led to statistically significant improvement in performance on a simulated resuscitation. RCDP and traditional low-fidelity simulation-based instruction may both be valuable tools to improve resuscitation skills in pediatric residents in resource-limited settings.

Effectiveness of a High-Fidelity Simulation-Based Training Program in Managing Cardiac Arrhythmias in Children: A Randomized Pilot Study

OBJECTIVES

Pediatric cardiac arrest is a rare event. Its management requires technical (TSs) and nontechnical skills (NTSs). We assessed the effectiveness of a simulation-based training to improve these skills in managing life-threatening pediatric cardiac arrhythmias.

METHODS

Four teams, each composed of 1 pediatric resident, 1 emergency medicine resident, and 2 pediatric nurses, were randomly assigned to the experimental group (EG) participating in 5 video-recorded simulation sessions with debriefing or to the control group (CG) assessed 2 times with video-recorded simulation sessions without debriefing at a 2-week interval. Questionnaires assessed self-reported changes in self-efficacy, stress, and satisfaction about skills. Blinded evaluators assessed changes in leaders' TSs and NTSs during the simulations and the time to initiate cardiopulmonary resuscitation.

RESULTS

After training, stress decreased and satisfaction about skills increased in the EG, whereas it remained the same in the CG (P = 0.014 and P < 0.001, respectively). There was no significant change in self-efficacy. Analyses of video-recorded skills showed significant improvements in TSs and NTSs of the EG leaders after training, but not of the CG leaders (P = 0.026, P = 0.038, respectively). The comparison of the evolution of the 2 groups concerning time to initiate cardiopulmonary resuscitation was not significantly different between the first and last simulation sessions.

CONCLUSIONS

A simulation-based training with debriefing had positive effects on stress and satisfaction about skills of pediatric residents and nurses and on observed TSs and NTSs of the leaders during simulation sessions. A future study should assess the effectiveness of this training in a larger sample and its impact on skills during actual emergencies.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.

Objective

The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.

Methods

We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.

Results

Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.

Conclusions

AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

Simulation for Milestone Assessment: Use of a Longitudinal Curriculum for Pediatric Residents

INTRODUCTION

Determining clinical competency on the milestones requires direct observation of residents, which is difficult for faculty members who are also providing patient care. Simulation can potentially represent an effective standardized tool for high-stakes assessment. Using a longitudinal simulation curriculum with formative and summative components, we conducted a pilot investigation to examine whether (1) performance on the formative cases predicted performance on the summative cases and (2) performance on the summative cases correlated with the clinical competency committee's (CCC) milestone placement.

METHODS

We developed 6 formative and 6 matched summative cases for pediatric interns that covered core pediatric topics. The interns progressed through the formative cases in pairs during the course of the academic year and then through the summative cases back to back individually at the end of the year. The interns were evaluated using a competency-based simulation evaluation. We determined the relationship between the formative and summative scores and between the summative scores and those from the CCC.

RESULTS

The relationship between formative and summative scores was not statistically significant. There was a statistically significant relationship between summative and CCC scores.

CONCLUSIONS

Significant methodological limitations preclude definite conclusions about the predictive power of simulation cases for Pediatric Milestones-based assessment. However, our work is an example of how simulation is a potentially useful tool for assessing residents' skill development on the Pediatric Milestones. More rigorous research is needed to determine the extent to which simulation can be used for high-stakes, milestones-based assessment.

Utility of a simple lighting device to improve chest compressions learning

INTRODUCTION

The recommendations on cardiopulmonary resuscitation (CPR) emphasize the quality of the manoeuvres, especially chest compressions (CC). Audiovisual feedback devices could improve the quality of the CC during CPR. The aim of this study was to evaluate the usefulness of a simple lighting device as a visual aid during CPR on a mannequin.

MATERIAL AND METHODS

Twenty-two paediatricians who attended an accredited paediatric CPR course performed, in random order, 2min of CPR on a mannequin without and with the help of a simple lighting device, which flashes at a frequency of 100 cycles per minute. The following CC variables were analyzed using a validated compression quality meter (CPRmeter^®): depth, decompression, rate, CPR time and percentage of compressions.

RESULTS

With the lighting device, participants increased average quality (60.23±54.50 vs. 79.24±9.80%; P=.005), percentage in target depth (48.86±42.67 vs. 72.95±20.25%; P=.036) and rate (35.82±37.54 vs. 67.09±31.95%; P=.024).

CONCLUSIONS

A simple light device that flashes at the recommended frequency improves the quality of CC performed by paediatric residents on a mannequin. The usefulness of this CPR aid system should be assessed in real patients.