Elaine Gilfoyle

Development of a leadership skills workshop in paediatric advanced resuscitation

Background: Paediatric residency programs rarely prepare trainees to assume resuscitation team leadership roles despite the recognized need for these skills by specialty accreditation organizations. We conducted a needs-assessment survey of all residents in the McGill Pediatric Residency Program, which demonstrated that most residents had minimal or no experience at leading resuscitation events and felt unprepared to assume this role in the future. Aims: We developed an educational intervention (workshop) and evaluated immediate and long term learning outcomes in order to determine whether residents could acquire and retain team leadership skills in pediatric advanced resuscitation. Methods: Fifteen paediatric residents participated in a workshop that we developed to fulfill the learning needs highlighted with the needs assessment, as well as the Objectives of Training in Pediatrics from the Royal College of Physicians and Surgeons of Canada. It consisted of a plenary session followed by 2 simulated resuscitation scenarios. Team performance was evaluated by checklist. Residents were evaluated again 6 months later without prior interactive lecture. Learning was also assessed by self-reported retrospective pre/post questionnaire. Results: Checklist score (assigning roles, limitations of team, communication, overall team atmosphere) expressed as % correct: initial workshop scenario 1 vs. scenario 2 (63 vs. 82 p < 0.05); 6-month scenario with prior workshop exposure vs. control (74 vs. 50 p < 0.01); initial workshop scenario 2 vs. 6-month scenario control (82 vs. 50 p < 0.001). Retrospective pre/post survey (5 point Likert scale) revealed self-reported learning in knowledge of tasks, impact and components of communication, avoidance of fixation errors and overall leadership performance (p < 0.001). Conclusions: Residents acquired resuscitation team leadership skills following an educational intervention as shown by both observational checklist scores and self-reported survey. The six-month follow-up evaluation demonstrated skill retention beyond the initial intervention. A control group suggested that these results were due to completion of the first workshop.

Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors*

Objective: To review the essential elements of crisis resource management and provide a resource for instructors by describing how to use simulation-based training to teach crisis resource management principles in pediatric acute care contexts. Data Source: A MEDLINE-based literature source. Outline of Review: This review is divided into three main sections: Background, Principles of Crisis Resource Management, and Tools and Resources. The background section provides the brief history and definition of crisis resource management. The next section describes all the essential elements of crisis resource management, including leadership and followership, communication, teamwork, resource use, and situational awareness. This is followed by a review of evidence supporting the use of simulation-based crisis resource management training in health care. The last section provides the resources necessary to develop crisis resource management training using a simulation-based approach. This includes a description of how to design pediatric simulation scenarios, how to effectively debrief, and a list of potential assessment tools that instructors can use to evaluate crisis resource management performance during simulation-based training. Conclusion: Crisis resource management principles form the foundation for efficient team functioning and subsequent error reduction in high-stakes environments such as acute care pediatrics. Effective instructor training is required for those programs wishing to teach these principles using simulation-based learning. Dissemination and integration of these principles into pediatric critical care practice has the potential for a tremendous impact on patient safety and outcomes.

Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention*

Objectives: To measure the effect of a 1-day team training course for pediatric interprofessional resuscitation team members on adherence to Pediatric Advanced Life Support guidelines, team efficiency, and teamwork in a simulated clinical environment. Design: Multicenter prospective interventional study. Setting: Four tertiary-care children’s hospitals in Canada from June 2011 to January 2015. Subjects: Interprofessional pediatric resuscitation teams including resident physicians, ICU nurse practitioners, registered nurses, and registered respiratory therapists (n = 300; 51 teams). Interventions: A 1-day simulation-based team training course was delivered, involving an interactive lecture, group discussions, and four simulated resuscitation scenarios, each followed by a debriefing. The first scenario of the day (PRE) was conducted prior to any team training. The final scenario of the day (POST) was the same scenario, with a slightly modified patient history. All scenarios included standardized distractors designed to elicit and challenge specific teamwork behaviors. Measurements and Main Results: Primary outcome measure was change (before and after training) in adherence to Pediatric Advanced Life Support guidelines, as measured by the Clinical Performance Tool. Secondary outcome measures were as follows: 1) change in times to initiation of chest compressions and defibrillation and 2) teamwork performance, as measured by the Clinical Teamwork Scale. Correlation between Clinical Performance Tool and Clinical Teamwork Scale scores was also analyzed. Teams significantly improved Clinical Performance Tool scores (67.3–79.6%; p < 0.0001), time to initiation of chest compressions (60.8–27.1 s; p < 0.0001), time to defibrillation (164.8–122.0 s; p < 0.0001), and Clinical Teamwork Scale scores (56.0–71.8%; p < 0.0001). A positive correlation was found between Clinical Performance Tool and Clinical Teamwork Scale (R2 = 0.281; p < 0.0001). Conclusions: Participation in a simulation-based team training educational intervention significantly improved surrogate measures of clinical performance, time to initiation of key clinical tasks, and teamwork during simulated pediatric resuscitation. A positive correlation between clinical and teamwork performance suggests that effective teamwork improves clinical performance of resuscitation teams.

A Randomized Controlled Trial of Corticosteroids in Pediatric Septic Shock: A Pilot Feasibility Study*

Objective: To determine the feasibility of conducting a randomized controlled trial of corticosteroids in pediatric septic shock. Design: Randomized, double-blind, placebo controlled trial. Setting: Seven tertiary level PICUs in Canada. Patients: Children newborn to 17 years old inclusive with suspected septic shock. Intervention: Administration of IV hydrocortisone versus placebo until hemodynamic stability is achieved or for a maximum of 7 days. Measurements and Main Results: One hundred seventy-four patients were potentially eligible of whom 101 patients met eligibility criteria. Fifty-seven patients were randomized, and 49 patients (23 and 26 patients in the hydrocortisone and placebo groups, respectively) were included in the final analysis. The mean time from screening to randomization was 2.4 ± 2.1 hours and from screening to first dose of study drug was 3.8 ± 2.6 hours. Forty-two percent of potentially eligible patients (73/174) received corticosteroids prior to randomization: 38.5% (67/174) were already on corticosteroids for shock at the time of screening, and in 3.4% (6/174), the treating physician wished to administer corticosteroids. Six of 49 randomized patients (12.2%) received open-label steroids, three in each of the hydrocortisone and placebo groups. Time on vasopressors, days on mechanical ventilation, PICU and hospital length of stay, and the rate of adverse events were not statistically different between the two groups. Conclusions: This study suggests that a large randomized controlled trial on early use of corticosteroids in pediatric septic shock is potentially feasible. However, the frequent use of empiric corticosteroids in otherwise eligible patients remains a significant challenge. Knowledge translation activities, targeted recruitment, and alternative study designs are possible strategies to mitigate this challenge.

Visual assessment of CPR quality during pediatric cardiac arrest: Does point of view matter?

AIM In many clinical settings, providers rely on visual assessment when delivering feedback on CPR quality. Little is known about the accuracy of visual assessment of CPR quality. We aimed to determine how accurate pediatric providers are in their visual assessment of CPR quality and to identify the optimal position relative to the patient for accurate CPR assessment. METHODS We videotaped high-quality CPR (based on 2010 American Heart Association guidelines) and 3 variations of poor quality CPR in a simulated resuscitation, filmed from the foot, head and the side of the manikin. Participants watched 12 videos and completed a questionnaire to assess CPR quality. RESULTS One hundred and twenty-five participants were recruited. The overall accuracy of visual assessment of CPR quality was 65.6%. Accuracy was better from the side (70.8%) and foot (68.8%) of the bed when compared to the head of the bed (57.2%; p<0.001). The side was the best position for assessing depth (p<0.001). Rate assessment was equivalent between positions (p=0.58). The side and foot of the bed were superior to the head when assessing chest recoil (p<0.001). Factors associated with increased accuracy in visual assessment of CPR quality included recent CPR course completion (p=0.034) and involvement in more cardiac arrests as a team member (p=0.003). CONCLUSION Healthcare providers struggle to accurately assess the quality of CPR using visual assessment. If visual assessment is being used, providers should stand at the side of the bed.

Determinants of Antibiotic Tailoring in Pediatric Intensive Care: A National Survey*

Objectives: To describe the criteria that currently guide empiric antibiotic treatment in children admitted to Canadian PICUs. Design: Cross-sectional survey. Setting: Canadian PICUs. Subjects: Pediatric intensivists and pediatric infectious diseases specialists. Interventions: None. Measurements and Main Results: We used focus groups and literature review to design the survey questions and its four clinical scenarios (sepsis, pneumonia, meningitis, and intra-abdominal infections). We analyzed our results using descriptive statistics and multivariate linear regression. Our response rate was 60% for pediatric intensivists (62/103) and 36% for pediatric infectious diseases specialists (37/103). Variables related to patient characteristics, disease severity, pathogens, and clinical, laboratory, and radiologic infection markers were associated with longer courses of antibiotics, with median increment ranging from 1.75 to 7.75 days. The presence of positive viral polymerase chain reaction result was the only variable constantly associated with a reduction in antibiotic use (median decrease from, –3.25 to –8.25 d). Importantly, 67–92% of respondents would still use a full course of antibiotics despite positive viral polymerase chain reaction result and marked clinical improvement for patients with suspected sepsis, pneumonia, and intra-abdominal infection. Clinical experience was associated with shorter courses of antibiotics for meningitis and sepsis (–1.3 d [95% CI, –2.4 to –0.2] and –1.8 d [95% CI, –2.8 to –0.7] per 10 extra years of clinical experience, respectively). Finally, site and specialty also influenced antibiotic practices. Conclusions: Decisions about antibiotic management for PICU patients are complex and involve the assessment of several different variables. With the exception of a positive viral polymerase chain reaction, our findings suggest that physicians rarely consider reducing the duration of antibiotics despite clinical improvement. In contrast, they will prolong the duration when faced with a nonreassuring characteristic. The development of objective and evidence-based criteria to guide antibiotic therapy in critically ill children is crucial to ensure the rational use of these agents in PICUs.

Simulation-Based Team Training

As many errors made in healthcare are due to human factors, training must target these issues in order to improve the quality of care provided. Interprofessional team training has been in existence in several areas of healthcare for many years, including pediatrics. Simulation-based training is the ideal teaching modality to employ for team training, especially for acute care teams (resuscitation teams, operating room teams, etc.). There is much to carefully consider when establishing a simulation-based team training program, including decisions to be made around the purpose of such training, who the participants are, and how to set up the simulated clinical environment. Published research has consistently demonstrated that teams that participate in simulation-based team training improve their knowledge, skills, and behaviors related to teamwork concepts. There are several high-quality assessment tools available that can be used to objectively evaluate teamwork behaviors in the simulated clinical environment. Future research should aim to provide more objective evidence demonstrating that team training in the simulated environment has a positive impact on patient outcomes in the real clinical environment.

The effect of hemoglobin levels on mortality in pediatric patients with severe traumatic brain injury

Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population.

A taxonomy and rating system to measure situation awareness in resuscitation teams

Team SA involves a common perspective between two or more individuals regarding current environmental events, their meaning, and projected future status. Team SA has been theorized to be important for resuscitation team effectiveness. Accordingly, multidimensional frameworks of observable behaviors relevant to resuscitation teams are needed to understand more deeply the nature of team SA, its implications for team effectiveness, and whether it can be trained. A seven-dimension team resuscitation SA framework was developed following a literature review and consensus process using a modified Delphi approach with a group of content experts. We applied a pre-post design within a day-long team training program involving four video-recorded simulated resuscitation events and 42 teams across Canada. The first and fourth events represented “pre” and “post” training events, respectively. Teams were scored on SA five times within each 15-minute event. Distractions were introduced to investigate whether SA scores would be affected. The current study provides initial construct validity evidence for a new measure of SA and explicates SAs role in resuscitation teams.

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

Background Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain. Methods Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management. Results 658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%). Interpretation Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.