James J. Fehr

Simulation-based Assessment of Pediatric Anesthesia Skills

BACKGROUND Assessment of pediatric anesthesia trainees is complicated by the random nature of adverse patient events and the vagaries of clinical exposure. However, assessment is critical to improve patient safety. In previous studies, a multiple scenario assessment provided reliable and valid measures of the abilities of anesthesia residents. The purpose of this study was to develop a set of relevant simulated pediatric perioperative scenarios and to determine their effectiveness in the assessment of anesthesia residents and pediatric anesthesia fellows. METHODS Ten simulation scenarios were designed to reflect situations encountered in perioperative pediatric anesthesia care. Anesthesiology residents and fellows consented to participate and were debriefed after each scenario. Two pediatric anesthesiologists scored each scenario by key action checklist. The psychometric properties (reliability, validity) of the scores were studied. RESULTS Thirty-five anesthesiology residents and pediatric anesthesia fellows participated. The participants with greater experience administering pediatric anesthetics generally outperformed those with less experience. Score variance attributable to raters was low, yielding a high interrater reliability. CONCLUSIONS A multiple-scenario, simulation-based assessment of pediatric perioperative care was designed and administered to residents and fellows. The scores obtained from the assessment indicated the content was relevant and that raters could reliably score the scenarios. Participants with more training achieved higher scores, but there was a wide range of ability among subjects. This method has the potential to contribute to pediatric anesthesia performance assessment, but additional measures of validity including correlations with more direct measures of clinical performance are needed to establish the utility of this approach.

Decision making in trauma settings: simulation to improve diagnostic skills.

Introduction In the setting of acute injury, a wrong, missed, or delayed diagnosis can impact survival. Clinicians rely on pattern recognition and heuristics to rapidly assess injuries, but an overreliance on these approaches can result in a diagnostic error. Simulation has been advocated as a method for practitioners to learn how to recognize the limitations of heuristics and develop better diagnostic skills. The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries. Methods Ten scenarios were developed to assess the ability of trauma teams to provide initial care to a severely injured patient. Seven standard scenarios simulated severe injuries that once diagnosed could be effectively treated using standard Advanced Trauma Life Support algorithms. Because diagnostic error occurs more commonly in complex clinical settings, 3 complex scenarios required teams to use more advanced diagnostic skills to uncover a coexisting condition and treat the patient. Teams composed of 3 to 5 practitioners were evaluated in the performance of 7 (of 10) randomly selected scenarios (5 standard, 2 complex). Expert rates scored teams using standardized checklists and global scores. Results Eighty-three surgery, emergency medicine, and anesthesia residents constituted 21 teams. Expert raters were able to reliably score the scenarios. Teams accomplished fewer checklist actions and received lower global scores on the 3 analytic scenarios (73.8% [12.3%] and 5.9 [1.6], respectively) compared with the 7 heuristic scenarios (83.2% [11.7%] and 6.6 [1.3], respectively; P < 0.05 for both). Teams led by more junior residents received higher global scores on the analytic scenarios (6.4 [1.3]) than the more senior team leaders (5.3 [1.7]). Conclusions This preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach. Simulation can be used to provide teams with decision-making experiences in trauma settings and could be used to improve diagnostic skills as well as study the decision-making process.

Paracorporeal lung assist device: An innovative surgical strategy for bridging to lung transplant in an infant with severe pulmonary hypertension caused by alveolar capillary dysplasia

Alveolar capillary dysplasia is a frequently fatal congenital pulmonary disease during infancy. Lung transplantation (LT) is the only means of survival. We report the case of an infant with alveolar capillary dysplasia who subsequently had development of severe hemodynamic compromise as a result of refractory pulmonary hypertension (PH) and was successfully bridged to LT with a paracorporeal lung assist device (PLAD) in a unique configuration.

Simulation in pediatric anesthesiology

Simulation‐based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer‐based simulations to mannequins. Computer‐controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in‐situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task‐training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.

Simulation-Based Assessment of ECMO Clinical Specialists.

Objective The aims of the study were (1) to create multiple scenarios that simulate a range of urgent and emergent extracorporeal membrane oxygenation (ECMO) events and (2) to determine whether these scenarios can provide reliable and valid measures of a specialist’s advanced skill in managing ECMO emergencies. Design Multiscenario simulation-based performance assessment was performed. Setting The study was conducted in the Saigh Pediatric Simulation Center at St. Louis Children’s Hospital. Subjects ECMO clinical specialists participated in the study. Measurements and Main Results Twenty-five ECMO specialists completed 8 scenarios presenting acute events in simulated ECMO patients. Participants were evaluated by 2 separate reviewers for completion of key actions and for global performance. The scores were highest for the hemodilution scenario, whereas the air entrainment scenario had the lowest scores. Psychometric analysis demonstrated that ECMO specialists with more than 1 year of experience outperformed the specialists with less than 1 year of experience. Participants endorsed these sessions as important and representative of events that might be encountered in practice. Conclusions The scenarios could serve as a component of an ECMO education curriculum and be used to assess clinical specialists’ readiness to manage ECMO emergencies.

The important role of simulation in sedation

Purpose of review This article reviews the development of simulation-based training strategies to educate sedation providers. Recent findings Medical simulation has been utilized to train and evaluate providers in numerous domains related to sedation. Sedation providers come to the patient with a wide range of clinical training and experience and simulation can serve as a platform for achieving a baseline skill level and for periodic retraining. Although widely accepted by participants in simulation training, data demonstrating simulations efficacy in improving sedation-related clinical outcomes are lacking. Summary Simulation provides an opportunity for sedation providers to develop deliberative practice, to consider rare or challenging clinical conditions, and to benefit from directed feedback, in a manner that does not put patients in harms way.

Emergency Information Forms for Children With Medical Complexity: A Simulation Study

BACKGROUND: Emergency information forms (EIFs) have been proposed to provide critical information for optimal care of children with medical complexity (CMC) during emergencies; however, their impact has not been studied. The objective of this study was to measure the impact and utility of EIFs in simulated scenarios of CMC during medical emergencies. METHODS: Twenty-four providers (12 junior, 12 experienced) performed 4 simulations of CMC, where access to an EIF was block randomized by group. Scenario-specific critical action checklists and consequential pathways were developed by content experts in simulation and pediatric subspecialists. Scenarios ended when all critical actions were completed or after 10 minutes, whichever came first. Two reviewers independently evaluated the video-recorded performances and calculated scenario-specific critical action scores. Performance in scenarios with and without an EIF was compared with Pearson’s χ2 and Mann–Whitney U tests. Interrater reliability was assessed with intraclass correlation. Each provider rated the utility of EIFs via exit questionnaires. RESULTS: The median critical action score in scenarios with EIFs was 84.2% (95% confidence interval [CI], 71.7%–94.1%) versus 12.5% (95% CI, 10.5%–35.3%) in scenarios without an EIF (P < .001); time to completion of scenarios was shorter (6.9 minutes [interquartile range 5.8–10 minutes] vs 10 minutes), and complication rates were lower (30% [95% CI, 17.4%–46.3%] vs 100% [95% CI, 92.2%–100%]) with EIFs, independent of provider experience. Interrater reliability was excellent (intraclass correlation = 0.979). All providers strongly agreed that EIFs can improve clinical outcomes for CMC. CONCLUSIONS: Using simulated scenarios of CMC, providers’ performance was superior with an EIF. Clinicians evaluated the utility of EIFs very highly.

Acute Care of Pediatric Patients With Sickle Cell Disease: A Simulation Performance Assessment

Sickle cell disease (SCD) is a rare disorder with cardinal features including hospitalization for vaso‐occlusive pain episodes, acute pulmonary injury, and increased infection rates. For physician‐trainees, learning optimal SCD management is challenging because of limited exposure to life threatening complications requiring timely interventions.

Perioperative Management of the Pediatric Cardiac Transplantation Patient

Opinion statementThe major diagnoses carried by children undergoing cardiac transplantation worldwide are congenital heart defects, cardiomyopathies, and retransplantation. The leading diagnosis in infancy is congenital heart disease, whereas cardiomyopathy predominates in older children. In view of this wide spectrum of diagnoses, the perioperative management of these children requires medical, interventional, and surgical expertise in treatment of complex congenital heart defects, end-stage heart failure, and cardiac transplantation. According to the Pediatric Heart Transplantation Survey database, the majority of children listed for cardiac transplantation eventually require higher levels of cardiac support before transplantation. The team caring for these children should be prepared to escalate support in a timely fashion in order to avoid end-organ dysfunction or a catastrophic event that will remove the patient from the cardiac transplantation list. The first step is advanced hemodynamic monitoring in a specialized pediatric cardiac intensive care unit and initiation of inotropic support. Further escalation of care should be based on careful analysis of the hemodynamic profile, end-organ function, and biochemical markers of perfusion and myocardial stress. A patient who continues to deteriorate in spite of inotropic support requires positive pressure ventilation, and if deterioration continues, mechanical circulatory support is initiated. Cardiac transplantation is a challenging operation, and even more so in children with complex congenital heart defects. The abnormal cardiovascular anatomy requires planning and anticipation of possible pitfalls as hypoplasia of the aortic arch, abnormal pulmonary arteries, and abnormal systemic and pulmonary venous connections. The time required to remove adhesions in children with prior cardiac operations increases the ischemic time of the graft and the risk of primary graft dysfunction. Assessment of pulmonary vascular resistance in children with congenital heart defects is problematic, and even children with a normal transpulmonary gradient and pulmonary vascular resistance are at increased risk of postoperative pulmonary hypertension and right ventricular graft failure. The postoperative course is directly linked to the patient’s preoperative physical condition and perioperative course. The induction of immunosuppression and the use of plasmapheresis in children with a positive cross-match may lead to further hemodynamic compromise. If severe primary graft dysfunction evolves, early initiation of extracorporeal membranous oxygenator is indicated to avoid irreversible end-organ dysfunction.

The Simulation-Based Assessment of Pediatric Rapid Response Teams

Objective To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists‐in‐training would be better prepared to manage the scenarios than teams led by nurse practitioners. Study design A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist‐in‐training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed. Results The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists‐in‐training outperformed the teams led by the pediatric nurse practitioners. Conclusions Simulation provides a method for RRTs to develop decision‐making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist‐in‐training‐led teams provides some evidence to support the validity of the assessment.