Jennifer Arnold

The Neonatal Resuscitation Program Comes of Age

T he Neonatal Resuscitation Program (NRP), established by the American Academy of Pediatrics and the American Heart Association, is the accepted standard for teaching neonatal resuscitation. The initial vision of the NRP was to provide effective intervention for newborns requiring resuscitation by a trained healthcare professional and develop a standardized educational program would promote optimal care in the resuscitation of sick newborns. In its short life-span, theNRP hasmatured with the implementationof best educational practices. From inception in1985until 2000, the curriculum was based on anecdotal evidence and scholarly speculations initially developed by champions Catherine Cropley, RN,MN, andRonald Bloom,MD. In the fourth edition of the NRP in 2000, the first organized review of existing scientific literature took place, aligning the curriculum with evidence-based guidelines. Now approaching its sixth edition, the NRP continues to be a leader in establishing the best evidenced-basedpractice for the care of newborns requiring resuscitation in the delivery room by inclusion of simulation-based training into the curriculum. A traditional NRP course consists of a day filled with textbook readings, lectures with accompanying slide presentations and videos, and skills stations at which trainees practice individual technical skills on partial-task trainers (low-tech mannequins andbody-part trainers such as intubationheads).With studies showing that cognitive and technical skills achieved in such standardized courses are retained for only 6 to 12 months, the goal of a simulation-based training curriculum is to improve sustained learning and skill in the care of newborns requiring resuscitation at the time of delivery.

A Structured End-of-Life Curriculum for Neonatal-Perinatal Postdoctoral Fellows.

Death in tertiary care neonatal intensive care units is a common occurrence. Despite recent advances in pediatric palliative education, evidence indicates that physicians are poorly prepared to care for dying infants and their families. Numerous organizations recommend increased training in palliative and end-of-life care for pediatric physicians. The purpose of this study is to develop a structured end-of-life curriculum for neonatal–perinatal postdoctoral fellows based on previously established principles and curricular guidelines on end-of-life care in the pediatric setting. Results demonstrate statistically significant curriculum effectiveness in increasing fellow knowledge regarding patient qualification for comfort care and withdrawal of support (P = .03). Although not statistically significant, results suggest the curriculum may have improved fellows’ knowledge of appropriate end-of-life medical management, comfort with addressing the family, and patient pain assessment and control.

Initial Development of C.A.T.E.S.: A Simulation-Based Competency Assessment Instrument for Neonatal Nurse Practitioners.

Abstract Purpose: Determine content validity of global statements and operational definitions and choose scenarios for Competency, Assessment, Technology, Education, and Simulation (C.A.T.E.S.), instrument in development to evaluate multidimensional competency of neonatal nurse practitioners (NNPs). Design: Real-time Delphi (RTD) method to pursue four specific aims (SAs): (1) identify which cognitive, technical, or behavioral dimension of NNP competency accurately reflects each global statement; (2) map the global statements to the National Association of Neonatal Nurse Practitioners (NANNP) core competency domains; (3) define operational definitions for the novice to expert performance subscales; and (4) determine the essential scenarios to assess NNPs. Sample: Twenty-five NNPs and nurses with competency and simulation experience Main outcome variable: One hundred percent of global statements correct for competency dimension and all but two correct for NANNP domain. One hundred percent novice to expert operational definitions and eight scenarios chosen. Results: Content validity determined for global statements and novice to expert definitions and essential scenarios chosen.

Humility in medicine

Becoming a physician comes with privilege and exciting opportunities. The rigor of academic medicine can be challenging. The ability to have humility as a physician is not only a sign of a good doctor, but it can be one of the most challenging attributes to maintain. My surgeon, Dr. Steven Kopits, embodied what it means to be a humble, yet accomplished physician.

Rapid Cycle Deliberate Practice: Application to Neonatal Resuscitation

Introduction This curriculum includes two simulation cases for neonatal resuscitation training using the rapid cycle deliberate practice (RCDP) technique. RCDP is a simulation-based curriculum that presents participants with rounds of increasing difficulty in rapid repetition, interspersing brief, direct feedback within the simulation. In contrast, traditional debriefing focuses on learning after the scenario is complete. Traditional debriefing usually utilizes advocacy-inquiry debriefing but allows less opportunity for practice. Methods Each case provides a neonatal resuscitation scenario (respiratory failure secondary to perinatal compromise and cardiac arrest secondary to placental abruption) for a term newborn in the delivery room. The curriculum utilizes high-fidelity neonatal mannequins with learner teams of three to six multidisciplinary teammates who participate in scenarios of increasing difficulty to revive a neonate. Learners can include a spectrum from beginning to advanced neonatal resuscitation providers. Learners are expected to perform the appropriate steps per the neonatal resuscitation program algorithm in addition to exhibiting effective crisis resource management skills. Results Immediate assessment of learner performance and feedback within the RCDP model is more directive, which allows for rapid resumption of practice. The instructor may also choose to pause and back up or to pause and restart, depending on the correction needed. Discussion Neonatal resuscitation program teaching utilizes a neonatal resuscitation performance evaluation, which may be used to guide opportunities for feedback within RCDP.

Simulation for Patient- and Family-Centered Care

Simulation for patient- and family-centered care recognizes that the patient and family are integral members of the healthcare team and should be encouraged to participate in their healthcare plan. This collaboration enhances respect, dignity, information sharing, and participation among all members of the team (i.e., healthcare providers and home caregivers) who are involved in the simulation. Instructor- and learner-centered objectives shape the scenarios and take into account the learners’ anxiety level and emotional state. Technical, cognitive, and behavioral skills may be taught through realistic scenarios that maintain the fidelity of the home caregiver’s environmental surroundings. The timing, frequency, and duration of the simulation may be influenced by the severity of the illness, urgency of the condition, complexity of the skills being taught, and the participants’ readiness to learn. Expectations of the simulation should be set for the learners during a pre-brief. This will give them an opportunity to better understand the active participation needed as they take part in this safe educational forum where they are encouraged to ask questions during repetitive practice. Debriefing simulation for patient- and family-centered care may include corrective feedback as well as time for reflection and discussion. Co-debriefing with non-healthcare providers with experience in patient- and family-centered care may also be beneficial.

Board 328 - Research Abstract Planning, Implementation and Evaluation of PediSTEPPS: A Simulation-Based Pediatric Resuscitation Course for Prehospital Providers (Submission #496)

Introduction/Background Prehospital providers rarely manage critically ill pediatric patients.1-3 Ongoing pediatric resuscitation education is critical to maintaining provider knowledge and skills. However, numerous barriers limit prehospital providers access to pediatric continuing education.2 Simulation-based education is ideally suited to resuscitation education and it has been used to identify performance deficiencies in paramedics for planning follow-up educational interventions.4,5 Methods A consensus group of experts in simulation, medical education, pediatric emergency medicine (PEM), prehospital pediatrics and emergency medical services (EMS) convened to develop goals and objectives for the course, focused on unique aspects of pediatric assessment, management, hands-on skills and teamwork in high-fidelity resuscitation scenarios. Detailed course materials were developed including lectures, skills station guides, high-fidelity scenario goals and objectives, manikin programs, scripted debriefings, debriefing checklists and confederate roles. Planned evaluations included pre and post-tests, self-efficacy checklists and a course satisfaction survey. All course materials were congruent with the prehospital protocols and scope of practice for the Emergency Medical Technician (EMT) - basic and paramedic provider levels of the City of Houston Fire Department (HFD) EMS. HFD EMS and PEM instructors were trained to teach PediSTEPPS. After initial curriculum development and instructor training, the curriculum was trialed with HFD EMS providers and then modified based on their feedback and the feedback of the HFD EMS medical directors. Results To date, PediSTEPPS has been taught for 8 months to a total of 209 participants. EMT-B pre and post-test scores increased from 64.4 % (95% CI: 62.3-66.5%) to 75.2% (95% CI: 73.6-76.9%) (p<0.001). They also increased from 68.3% (95% CI: 65.9-70.7%) to 80.2% (78.2-82.1%) for EMT-Ps (p<0.001). On a 5 point Likert scale (1 = strongly disagree; 5 = strongly agree), the mean participant ratings were as follows: “Simulation is the appropriate methodology to teach this material,” mean = 4.70 (range 2-5); “The course was appropriate for my level of learning,” mean = 4.64 (range 1-5); “This course has improved my clinical knowledge,” mean = 4.70 (range 3-5); and “I plan to apply what I learned here to my clinical practice,” mean 4.81 (range 3-5). The lowest satisfaction was with “The simulation center environment is realistic to my clinical environment,” mean = 4.28 (range 1-5). Conclusion Multidisciplinary collaboration between simulation-based medical educators, PEM physicians and EMS providers is feasible. PediSTEPPS significantly improved provider knowledge scores immediately after completion of the course for both EMT-B and EMT-P providers. Implementing a simulation-based pediatric resuscitation course with consideration of EMT-Basic and paramedic level providers scope of practice is associated with high learner satisfaction. Simulating a realistic prehospital environment remains challenging. Future work will evaluate knowledge and skills retention, self-efficacy and clinical performance. References 1. Gausche M, Henderson DP, Seidel JS. Vital Signs as Part of the Prehospital Assessment of the Pediatric Patient: A Survey of Paramedics. Annals of Emergency Medicine. 1990; 19(2): 173-178. 2. Glaeser PW, Linzer J, Tunik MG, Henderson DP, Ball J. Survey of Nationally Registered Emergency Medical Services Providers: Pediatric Education. Annals of Emergency Medicine. 2000; 36(1): 33-38. 3. Graham CJ, Stuemky J, Lera TA. Emergency Medical Services Preparedness for Pediatric Emergencies. Pediatric Emergency Care. 1993; 9(6): 329-331. 4. Miller DR, Kalinowski EJ, Wood D. Pediatric continuing education for EMTs: Recommendations for content, method, and frequency. Pediatric Emergency Care 2004; 20(4): 269-272. 5. Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic resuscitation skills. Prehospital Emergency Care 2009;13:345-356. Disclosures Laerdal Foundation for Acute Medicine Cord Blood Registry- non simulation related.