Allison A. Murphy

High-fidelity simulation-based training in neonatal nursing.

Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills.

Background: Healthcare professionals are expected to make rapid, correct decisions in critical situations despite what may be a lack of real practical experience in a particular crisis situation. Successful resolution of a medical crisis depends upon demonstration not only of appropriate technical skills but also of key behavioral skills (eg, leadership, communication, and teamwork). We have developed a hands-on, high fidelity, simulation-based training program (ECMO Sim) to provide healthcare professionals with the opportunity to learn and practice the technical and behavioral skills necessary to manage ECMO emergencies. Methods: Nine ECMO nurse specialists participated in two sequential randomly assigned simulated ECMO emergencies. The simulated emergencies were captured on videotape and reviewed with the subjects during facilitated debriefings that occurred immediately following each scenario. All videotapes were scored for key technical and behavioral skills by reviewers blinded to the sequence of the scenarios. The ratings of the subjects’ technical and behavioral skills in each scenario were compared. Results: Subjects performed key technical skills correctly more often in the second simulated ECMO emergency. In addition, their response times for three out of five specific technical tasks improved from the first to the second simulated emergency by an average of 27 seconds. Subjects’ behavioral skills were rated more highly by masked reviewers in the second simulated ECMO emergency. The improvement in comprehensive behavioral scores from the first to the second scenario reached statistical significance in eight of nine subjects. Conclusion: After exposure to high-fidelity simulated ECMO emergencies, subjects demonstrated significant improvements in their technical and behavioral skills. ECMO Sim creates a learning environment that readily supports the acquisition of the technical and behavioral skills that are important in solving clinically significant, potentially life-threatening problems that can occur when patients are on ECMO.

Comparing the Utility of a Standard Pediatric Resuscitation Cart With a Pediatric Resuscitation Cart Based on the Broselow Tape: A Randomized, Controlled, Crossover Trial Involving Simulated Resuscitation Scenarios

Background. Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, childrens hospitals and clinics have used a standard pediatric resuscitation cart (“standard cart”) in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape (“Broselow cart”) in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart. Objectives. To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios. Results. Of the 21 subjects, 62% found the Broselow cart “easy” or “very easy” to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart. Conclusions. Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.

Background: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. Methods: A survey was conducted at the 19th Annual Children’s National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. Results: Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. Conclusion: Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Training and competency assessment in electronic fetal monitoring: a national survey

OBJECTIVE To investigate current patterns of training and competency assessment in electronic fetal monitoring (EFM) for obstetrics and gynecology residents and maternal–fetal medicine fellows. METHODS A questionnaire was mailed to the directors of all 254 accredited US residencies in obstetrics and gynecology and 61 accredited US fellowships in maternal–fetal medicine. Questions focused on the methods used for teaching and assessing competency in EFM. RESULTS Two hundred thirty-nine programs (76%) responded to the survey. Clinical experience is used by 219 programs (92%) to teach EFM, both initially and on an ongoing basis. Significantly more residencies than fellowships use written materials and lectures to teach EFM. More than half of all programs require trainees to participate in some type of EFM training at least every 6 months; 23 programs (10%) have no requirement at all. Subjective evaluation is used by 174 programs (73%) to assess competency in EFM. Written or oral examinations, skills checklists, and logbooks are used exclusively by residencies as means of competency assessment. Two thirds of all programs assess EFM skills at least every 6 months; 40 programs (17%), the majority of which are fellowships, have no formal requirement. CONCLUSION Most US training programs use supervised clinical experience as both their primary source of teaching EFM and their principal competency assessment tool. Residencies are more likely to have formal instruction and assessment than are fellowships. Few programs are using novel strategies (eg, computers or simulators) in their curriculum