Christine E. Watson

Effect of Just-in-time Simulation Training on Tracheal Intubation Procedure Safety in the Pediatric Intensive Care Unit

Background:Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during intensive care unit rotations. The authors hypothesized that “just-in-time” simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs. Methods:For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non–refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared. Results:Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non–refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The residents first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28–3.87, P = 0.005). Conclusions:Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the residents first attempt or overall tracheal intubation success.

Action concepts in the brain: An activation likelihood estimation meta-analysis

Many recent neuroimaging studies have investigated the representation of semantic memory for actions in the brain. We used activation likelihood estimation (ALE) meta-analyses to answer two outstanding questions about the neural basis of action concepts. First, on an “embodied” view of semantic memory, evidence to date is unclear regarding whether visual motion or motor systems are more consistently engaged by action concepts. Second, few studies have directly investigated the possibility that action concepts accessed verbally or nonverbally recruit different areas of the brain. Because our meta-analyses did not include studies requiring the perception of dynamic depictions of actions or action execution, we were able to determine whether conceptual processing alone recruits visual motion and motor systems. Significant concordance in brain regions within or adjacent to visual motion areas emerged in all meta-analyses. By contrast, we did not observe significant concordance in motor or premotor cortices in any analysis. Neural differences between action images and action verbs followed a gradient of abstraction among representations derived from visual motion information in the left lateral temporal and occipital cortex. The consistent involvement of visual motion but not motor brain regions in representing action concepts may reflect differences in the variability of experience across individuals with perceiving versus performing actions.

A bilateral frontoparietal network underlies visuospatial analogical reasoning.

Our ability to reason by analogy facilitates problem solving and allows us to communicate ideas efficiently. In this study, we examined the neural correlates of analogical reasoning and, more specifically, the contribution of rostrolateral prefrontal cortex (RLPFC) to reasoning. This area of the brain has been hypothesized to integrate relational information, as in analogy, or the outcomes of subgoals, as in multi-tasking and complex problem solving. Using fMRI, we compared visuospatial analogical reasoning to a control task that was as complex and difficult as the analogies and required the coordination of subgoals but not the integration of relations. We found that analogical reasoning more strongly activated bilateral RLPFC, suggesting that anterior prefrontal cortex is preferentially recruited by the integration of relational knowledge. Consistent with the need for inhibition during analogy, bilateral, and particularly right, inferior frontal gyri were also more active during analogy. Finally, greater activity in bilateral inferior parietal cortex during the analogy task is consistent with recent evidence for the neural basis of spatial relation knowledge. Together, these findings indicate that a network of frontoparietal areas underlies analogical reasoning; we also suggest that hemispheric differences may emerge depending on the visuospatial or verbal/semantic nature of the analogies.

Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit

Objective: Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. Design: Prospective, observational pilot study. Setting: Single tertiary childrens hospital pediatric intensive care unit. Subjects: Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. Interventions: A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. Measurements and Main Results: For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd). Conclusions: It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

A randomized, controlled trial of in situ pediatric advanced life support recertification ("pediatric advanced life support reconstructed") compared with standard pediatric advanced life support recertification for ICU frontline providers*.

Objective:Recent evidence shows poor retention of Pediatric Advanced Life Support provider skills. Frequent refresher training and in situ simulation are promising interventions. We developed a “Pediatric Advanced Life Support–reconstructed” recertification course by deconstructing the training into six 30-minute in situ simulation scenario sessions delivered over 6 months. We hypothesized that in situ Pediatric Advanced Life Support–reconstructed implementation is feasible and as effective as standard Pediatric Advanced Life Support recertification. Design:A prospective randomized, single-blinded trial. Setting:Single-center, large, tertiary PICU in a university-affiliated children’s hospital. Subjects:Nurses and respiratory therapists in PICU. Interventions:Simulation-based modular Pediatric Advanced Life Support recertification training. Measurements and Main Results:Simulation-based pre- and postassessment sessions were conducted to evaluate participants’ performance. Video-recorded sessions were rated by trained raters blinded to allocation. The primary outcome was skill performance measured by a validated Clinical Performance Tool, and secondary outcome was behavioral performance measured by a Behavioral Assessment Tool. A mixed-effect model was used to account for baseline differences. Forty participants were prospectively randomized to Pediatric Advanced Life Support reconstructed versus standard Pediatric Advanced Life Support with no significant difference in demographics. Clinical Performance Tool score was similar at baseline in both groups and improved after Pediatric Advanced Life Support reconstructed (pre, 16.3 ± 4.1 vs post, 22.4 ± 3.9; p < 0.001), but not after standard Pediatric Advanced Life Support (pre, 14.3 ± 4.7 vs post, 14.9 ± 4.4; p =0.59). Improvement of Clinical Performance Tool was significantly higher in Pediatric Advanced Life Support reconstructed compared with standard Pediatric Advanced Life Support (p = 0.006). Behavioral Assessment Tool improved in both groups: Pediatric Advanced Life Support reconstructed (pre, 33.3 ± 4.5 vs post, 35.9 ± 5.0; p = 0.008) and standard Pediatric Advanced Life Support (pre, 30.5 ± 4.7 vs post, 33.6 ± 4.9; p = 0.02), with no significant difference of improvement between both groups (p = 0.49). Conclusions:For PICU-based nurses and respiratory therapists, simulation-based “Pediatric Advanced Life Support–reconstructed” in situ training is feasible and more effective than standard Pediatric Advanced Life Support recertification training for skill performance. Both Pediatric Advanced Life Support recertification training courses improved behavioral performance.

Shared and distinct neuroanatomic regions critical for tool-related action production and recognition: Evidence from 131 left-hemisphere stroke patients

The inferior frontal gyrus and inferior parietal lobe have been characterized as human homologues of the monkey “mirror neuron” system, critical for both action production (AP) and action recognition (AR). However, data from brain lesion patients with selective impairment on only one of these tasks provide evidence of neural and cognitive dissociations. We sought to clarify the relationship between AP and AR, and their critical neural substrates, by directly comparing performance of 131 chronic left-hemisphere stroke patients on both tasks—to our knowledge, the largest lesion-based experimental investigation of action cognition to date. Using voxel-based lesion-symptom mapping, we found that lesions to primary motor and somatosensory cortices and inferior parietal lobule were associated with disproportionately impaired performance on AP, whereas lesions to lateral temporo-occipital cortex were associated with a relatively rare pattern of disproportionately impaired performance on AR. In contrast, damage to posterior middle temporal gyrus was associated with impairment on both AP and AR. The distinction between lateral temporo-occipital cortex, critical for recognition, and posterior middle temporal gyrus, important for both tasks, suggests a rough gradient from modality-specific to abstract representations in posterior temporal cortex, the first lesion-based evidence for this phenomenon. Overall, the results of this large patient study help to bring closure to a long-standing debate by showing that tool-related AP and AR critically depend on both common and distinct left hemisphere neural substrates, most of which are external to putative human mirror regions.

The functional neuroanatomy of actions

Our current understanding of the neural basis of semantic memory is informed primarily by studies of concrete objects. However, conceptual knowledge encompasses many other, albeit less concrete, domains. This article reviews evidence from neuroimaging and patient studies that speaks to the neural basis of action concepts and the words that refer to them. These data highlight 2 important principles governing the neural instantiation of semantic knowledge. First, the organization of conceptual representations in the brain parallels perception and action. Action concepts are at least partially represented within modality-specific areas responsible for the perception and execution of dynamic actions. Second, unimodal sensory and motor cortices act as “points of entry” for more abstract action knowledge. Increasingly abstract conceptual knowledge derived from these modalities is represented in brain areas located anterior and centripetal to modality-specific regions. Extending research on the neural basis of semantics to include dynamic and relational aspects of the world gives us a more complete appreciation of the range of cognitive and communication impairments that may be experienced by patients with neurologic disease.

SOS! An algorithm and software for the stochastic optimization of stimuli.

The characteristics of the stimuli used in an experiment critically determine the theoretical questions the experiment can address. Yet there is relatively little methodological support for selecting optimal sets of items, and most researchers still carry out this process by hand. In this research, we present SOS, an algorithm and software package for the stochastic optimization of stimuli. SOS takes its inspiration from a simple manual stimulus selection heuristic that has been formalized and refined as a stochastic relaxation search. The algorithm rapidly and reliably selects a subset of possible stimuli that optimally satisfy the constraints imposed by an experimenter. This allows the experimenter to focus on selecting an optimization problem that suits his or her theoretical question and to avoid the tedious task of manually selecting stimuli. We detail how this optimization algorithm, combined with a vocabulary of constraints that define optimal sets, allows for the quick and rigorous assessment and maximization of the internal and external validity of experimental items. In doing so, the algorithm facilitates research using factorial, multiple/mixed-effects regression, and other experimental designs. We demonstrate the use of SOS with a case study and discuss other research situations that could benefit from this tool. Support for the generality of the algorithm is demonstrated through Monte Carlo simulations on a range of optimization problems faced by psychologists. The software implementation of SOS and a user manual are provided free of charge for academic purposes as precompiled binaries and MATLAB source files at http://sos.cnbc.cmu.edu.

The specificity of action knowledge in sensory and motor systems

Neuroimaging studies have found that sensorimotor systems are engaged when participants observe actions or comprehend action language. However, most of these studies have asked the binary question of whether action concepts are embodied or not, rather than whether sensory and motor areas of the brain contain graded amounts of information during putative action simulations. To address this question, we used repetition suppression (RS) functional magnetic resonance imaging to determine if functionally-localized motor movement and visual motion regions-of-interest (ROI) and two anatomical ROIs (inferior frontal gyrus, IFG; left posterior middle temporal gyrus, pMTG) were sensitive to changes in the exemplar (e.g., two different people “kicking”) or representational format (e.g., photograph or schematic drawing of someone “kicking”) within pairs of action images. We also investigated whether concrete versus more symbolic depictions of actions (i.e., photographs or schematic drawings) yielded different patterns of activation throughout the brain. We found that during a conceptual task, sensory and motor systems represent actions at different levels of specificity. While the visual motion ROI did not exhibit RS to different exemplars of the same action or to the same action depicted by different formats, the motor movement ROI did. These effects are consistent with “person-specific” action simulations: if the motor system is recruited for action understanding, it does so by activating ones own motor program for an action. We also observed significant repetition enhancement within the IFG ROI to different exemplars or formats of the same action, a result that may indicate additional cognitive processing on these trials. Finally, we found that the recruitment of posterior brain regions by action concepts depends on the format of the input: left lateral occipital cortex and right supramarginal gyrus responded more strongly to symbolic depictions of actions than concrete ones.

Development of an Instrument for a Primary Airway Provider's Performance With an ICU Multidisciplinary Team in Pediatric Respiratory Failure Using Simulation

OBJECTIVE: To develop a scoring system that can assess the multidisciplinary management of respiratory failure in a pediatric ICU. METHODS: In a single tertiary pediatric ICU we conducted a simulation-based evaluation in a patient care area auxiliary to the ICU. The subjects were pediatric and emergency medicine residents, nurses, and respiratory therapists who work in the pediatric ICU. A multidisciplinary focus group with experienced providers in pediatric ICU airway management and patient safety specialists was formed. A task-based scoring instrument was developed to evaluate a primary airway providers performance through Healthcare Failure Mode and Effect Analysis. Reliability and validity of the instrument were evaluated using multidisciplinary simulation-based airway management training sessions. Each session was evaluated by 3 independent expert raters. A global assessment of the team performance and the previous experience in training were used to evaluate the validity of the instrument. RESULTS: The Just-in-Time Pediatric Airway Provider Performance Scale (JIT-PAPPS) version 3, with 34 task-based items (14 technical, 20 behavioral), was developed. Eighty-five teams led by resident airway providers were evaluated by 3 raters. The intraclass correlation coefficient for raters was 0.64. The JIT-PAPPS score correlated well with the global rating scale (r = 0.71, P < .001). Mean total scores across the teams were positively associated with resident previous training participation (β coefficient 7.1 ± 0.9, P < .001), suggesting good validity of the scale. CONCLUSIONS: A task-based scoring instrument for a primary airway providers performance with a multidisciplinary pediatric ICU team on simulated pediatric respiratory failure was developed. Reliability and validity evaluation supports the developed scale.