Simulation in pediatric anesthesiology: current state and visions for the future

PURPOSE OF REVIEW

Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future.

RECENT FINDINGS

Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future.

SUMMARY

Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed.

Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project

BACKGROUND

Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia.

AIMS

We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations.

METHODS

The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart.

RESULTS

After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001).

CONCLUSION

Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.

Checklists and cognitive aids: underutilized and under-researched tools to promote patient safety and optimize clinician performance

PURPOSE OF REVIEW

Checklists and other cognitive aids serve multiple purposes in the peri-operative setting and have become nearly ubiquitous in healthcare. This review lays out the evidence for their use, shortcomings and pitfalls to be aware of, and how technology and innovation may improve checklist and cognitive aid relevance and usability.

RECENT FINDINGS

It has been difficult to show a direct link between the use of checklists alone and patient outcomes, but simulation studies have repeatedly demonstrated an association between checklist or cognitive aid use and improved performance. When implemented as part of a bundle of interventions, checklists likely have a positive impact, but the benefit of checklists and other cognitive aids may be both context- and user dependent. Advances in technology and automation demonstrate promise, but usability, design, and implementation research in this area are necessary to maximize effectiveness.

SUMMARY

Cognitive aids like checklists are powerful tools in the perioperative and critical care setting. Further research and innovation may elevate what is possible by improving the usability and relevance of these tools, possibly translating into improved patient outcomes.

Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice

BACKGROUND

Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over-dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division.

METHODS

The division consisted of 63 faculty, 11 clinical fellows, 32 residents, and 28 nurse anesthetists at the Children's Hospital of Philadelphia. The program was assessed for effectiveness (a significant improvement in EEG knowledge scores), scalability (training 50% of fellows and staff), and sustainability (recurring EEG lectures for 80% of rotating residents and 100% of new fellows and staff). The key drivers included educational content development (lectures, articles, and hand-outs), training a cohort of EEG TIVA trainers, intraoperative teaching (teaching points and dosing tables), decision support tools (algorithms and anesthesia electronic record pop-ups), and knowledge tests (written exam and verbal quiz during cases).

RESULTS

Over 12 months, 78.5% of the division (62/79) completed EEG training and test scores improved (mean score 38% before training vs 59% after training, p < .001). Didactic lectures were given to 100% of the fellows, 100% (11/11) of new staff, and 80% (4/5 blocks) of rotating residents.

CONCLUSION

This quality improvement education project successfully trained pediatric anesthesia faculty, staff, residents, and fellows in EEG-guided TIVA. The training program was effective, scalable, and sustainable over time for newly hired faculty staff and rotating fellows and residents.

Practice what you teach: An approach to integrate airway education for experienced anesthesia clinicians

BACKGROUND

The COVID-19 pandemic has disrupted clinician education. To address this challenge, our divisional difficult airway program (AirEquip) designed and implemented small-group educational workshops for experienced clinicians. Our primary aim was to test the feasibility and acceptability of a small-group, flexible-curriculum skills workshop conducted during the clinical workday. Secondary objectives were to evaluate whether our workshop increased confidence in performing relevant skills and to assess the work-effort required for the new program.

METHODS

We implemented a 1:1 and 2:1 (participant to facilitator ratio) airway skills workshop for experienced clinicians during the workday. A member of the AirEquip team temporarily relieved the attendee of clinical duties to facilitate participation. Attendance was encouraged but not required. Feasibility was assessed by clinician attendance, and acceptability was assessed using three Likert scale questions and derived from free-response feedback. Participants completed pre and postworkshop surveys to assess familiarity and comfort with various aspects of airway management. A work-effort analysis was conducted and compared to the effort to run a previously held larger-format difficult airway conference.

RESULTS

Fifteen workshops were conducted over 7 weeks; members of AirEquip were able to temporarily assume participants' clinical duties. Forty-seven attending anesthesiologists and 17 CRNAs attended the workshops, compared with six attending anesthesiologists and five CRNAs who attended the most recent larger-format conference. There was no change in confidence after workshop participation, but participants overwhelmingly expressed enthusiasm and satisfaction with the workshops. The number of facilitator person-hours required to operate the workshops (105 h) was similar to that required to run a single all-day larger-format conference (104.5 h).

CONCLUSION

It is feasible and acceptable to incorporate expert-led skills training into the clinical workday. Alongside conferences and large-format instruction, this modality enhances the way we are able to share knowledge with our colleagues. This concept can likely be applied to other skills in various clinical settings.

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.

Examining novice anaesthesia trainee simulation performance: a tale of two clusters

Introduction

Understanding performance differences between learners may provide useful context for optimising medical education. This pilot study aimed to explore a technique to contextualise performance differences through retrospective secondary analyses of two randomised controlled simulation studies. One study focused on speaking up (non-technical skill); the other focused on oxygen desaturation management (technical skill).

Methods

We retrospectively analysed data from two independent simulation studies conducted in 2017 and 2018. We used multivariate hierarchical cluster analysis to explore whether participants in each study formed homogenous performance clusters. We then used mixed-design analyses of variance and χ2 analyses to examine whether reported task load differences or demographic variables were associated with cluster membership.

Results

In both instances, a two-cluster solution emerged; one cluster represented trainees exhibiting higher performance relative to peers in the second cluster. Cluster membership was independent of experimental allocation in each of the original studies. There were no discernible demographic differences between cluster members. Performance differences between clusters persisted for at least 8 months for the non-technical skill but quickly disappeared following simulation training for the technical skill. High performers in speaking up initially reported lower task load than standard performers, a difference that disappeared over time. There was no association between performance and task load during desaturation management.

Conclusion

This pilot study suggests that cluster analysis can be used to objectively identify high-performing trainees for both a technical and a non-technical skill as observed in a simulated clinical setting. Non-technical skills may be more difficult to teach and retain than purely technical ones, and there may be an association between task load and initial non-technical performance. Further study is needed to understand what factors may confer inherent performance advantages, whether these advantages translate to clinical performance and how curricula can best be designed to drive targeted improvement for individual trainees.

Development of a scale to measure intrapersonal factors influencing speaking up in the operating room

INTRODUCTION

This paper reports on the development of a scale to measure intrapersonal factors (IPF) that may influence speaking up behaviour in the operating room.

METHODS

Participants were postgraduate year 2, 3, and 4 anaesthesiology residents and practising faculty anaesthesiologists at a large quaternary care academic hospital. Based on a literature review, the authors constructed the initial scale. Exploratory factor analysis was conducted to identify the underlying factor structure for the scale. A set of one-way ANOVAs and multiple ordinal regressions were carried out to provide additional validity evidence for the new scale.

RESULTS

Exploratory factor analysis indicated a three-factor solution accounting for 73% of the variance. The self-efficacy subscale included four items (Cronbach's α = 0.86), and the social outcome expectations (Cronbach's α = 0.86) and assertive attitude (Cronbach's α = 0.67) subscales contained three items each. The effect of training level was significantly associated with self-efficacy (p < 0.001) and assertive attitude subscale scores (p < 0.001). Multiple ordinal regressions indicated that IPF predicted participants' likelihood of speaking up in various hypothetical scenarios.

DISCUSSION

Our analyses provided initial evidence for the validity and reliability of a 10-item IPF scale. This instrument needs to be validated in other cohorts.