Jordan Duval-Arnould

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Healthcare-associated infections are common, costly, and often lethal. Although there is growing pressure to reduce these infections, one project thus far has unprecedented collaboration among many groups at every level of health care. After this project produced a 66% reduction in central catheter-associated bloodstream infections and a median central catheter-associated bloodstream infection rate of zero across >100 intensive care units in Michigan, the Agency for Healthcare Research and Quality awarded a grant to spread this project to ten additional states. A program, called On the CUSP: Stop BSI, was formulated from the Michigan project, and additional funding from the Agency for Healthcare Research and Quality and private philanthropy has positioned the program for implementation state by state across the United States. Furthermore, the program is being implemented throughout Spain and England and is undergoing pilot testing in several hospitals in Peru. The model in this program balances the tension between being scientifically rigorous and feasible. The three main components of the model include translating evidence into practice at the bedside to prevent central catheter-associated bloodstream infections, improving culture and teamwork, and having a data collection system to monitor central catheter-associated bloodstream infections and other variables. If successful, this program will be the first national quality improvement program in the United States with quantifiable and measurable goals.

Reporting guidelines for health care simulation research: Extensions to the CONSORT and STROBE statements

BackgroundSimulation-based research (SBR) is rapidly expanding but the quality of reporting needs improvement. For a reader to critically assess a study, the elements of the study need to be clearly reported. Our objective was to develop reporting guidelines for SBR by creating extensions to the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statements.MethodsAn iterative multistep consensus-building process was used on the basis of the recommended steps for developing reporting guidelines. The consensus process involved the following: (1) developing a steering committee, (2) defining the scope of the reporting guidelines, (3) identifying a consensus panel, (4) generating a list of items for discussion via online premeeting survey, (5) conducting a consensus meeting, and (6) drafting reporting guidelines with an explanation and elaboration document.ResultsThe following 11 extensions were recommended for CONSORT: item 1 (title/abstract), item 2 (background), item 5 (interventions), item 6 (outcomes), item 11 (blinding), item 12 (statistical methods), item 15 (baseline data), item 17 (outcomes/ estimation), item 20 (limitations), item 21 (generalizability), and item 25 (funding). The following 10 extensions were recommended for STROBE: item 1 (title/abstract), item 2 (background/rationale), item 7 (variables), item 8 (data sources/measurement), item 12 (statistical methods), item 14 (descriptive data), item 16 (main results), item 19 (limitations), item 21 (generalizability), and item 22 (funding). An elaboration document was created to provide examples and explanation for each extension.ConclusionsWe have developed extensions for the CONSORT and STROBE Statements that can help improve the quality of reporting for SBR (Sim Healthcare 00:00-00, 2016).

Structuring feedback and debriefing to achieve mastery learning goals

Mastery learning is a powerful educational strategy in which learners gain knowledge and skills that are rigorously measured against predetermined mastery standards with different learners needing variable time to reach uniform outcomes. Central to mastery learning are repetitive deliberate practice and robust feedback that promote performance improvement. Traditional health care simulation involves a simulation exercise followed by a facilitated postevent debriefing in which learners discuss what went well and what they should do differently next time, usually without additional opportunities to apply the specific new knowledge. Mastery learning approaches enable learners to “try again” until they master the skill in question. Despite the growing body of health care simulation literature documenting the efficacy of mastery learning models, to date insufficient details have been reported on how to design and implement the feedback and debriefing components of deliberate-practice-based educational interventions. Using simulation-based training for adult and pediatric advanced life support as case studies, this article focuses on how to prepare learners for feedback and debriefing by establishing a supportive yet challenging learning environment; how to implement educational interventions that maximize opportunities for deliberate practice with feedback and reflection during debriefing; describing the role of within-event debriefing or “microdebriefing” (i.e., during a pause in the simulation scenario or during ongoing case management without interruption), as a strategy to promote performance improvement; and highlighting directions for future research in feedback and debriefing for mastery learning.

Reporting Guidelines for Health Care Simulation Research

Introduction Simulation-based research (SBR) is rapidly expanding but the quality of reporting needs improvement. For a reader to critically assess a study, the elements of the study need to be clearly reported. Our objective was to develop reporting guidelines for SBR by creating extensions to the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statements. Methods An iterative multistep consensus-building process was used on the basis of the recommended steps for developing reporting guidelines. The consensus process involved the following: (1) developing a steering committee, (2) defining the scope of the reporting guidelines, (3) identifying a consensus panel, (4) generating a list of items for discussion via online premeeting survey, (5) conducting a consensus meeting, and (6) drafting reporting guidelines with an explanation and elaboration document. Results The following 11 extensions were recommended for CONSORT: item 1 (title/abstract), item 2 (background), item 5 (interventions), item 6 (outcomes), item 11 (blinding), item 12 (statistical methods), item 15 (baseline data), item 17 (outcomes/estimation), item 20 (limitations), item 21 (generalizability), and item 25 (funding). The following 10 extensions were recommended for STROBE: item 1 (title/abstract), item 2 (background/rationale), item 7 (variables), item 8 (data sources/measurement), item 12 (statistical methods), item 14 (descriptive data), item 16 (main results), item 19 (limitations), item 21 (generalizability), and item 22 (funding). An elaboration document was created to provide examples and explanation for each extension. Conclusions We have developed extensions for the CONSORT and STROBE Statements that can help improve the quality of reporting for SBR.

Simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: A randomized controlled trial

BACKGROUND Traditional American Heart Association (AHA) cardiopulmonary resuscitation (CPR) curriculum focuses on teams of two performing quality chest compressions with rescuers on their knees but does not include training specific to In-Hospital Cardiac Arrests (IHCA), i.e. patient in hospital bed with large resuscitation teams and sophisticated technology available. DESIGN A randomized controlled trial was conducted with the primary goal of evaluating the effectiveness and ideal frequency of in-situ training on time elapsed from call for help to; (1) initiation of chest compressions and (2) successful defibrillation in IHCA. METHODS Non-intensive care unit nurses were randomized into four groups: standard AHA training (C) and three groups that participated in 15 min in-situ IHCA training sessions every two (2M), three (3M) or six months (6M). Curriculum included specific choreography for teams to achieve immediate chest compressions, high chest compression fractions and rapid defibrillation while incorporating use of a backboard, stepstool. RESULTS More frequent training was associated with decreased median (IQR) seconds to: starting compressions: [C: 33(25-40) vs. 6M: 21(15-26) vs. 3M: 14(10-20) vs. 2M: 13(9-20); p < 0.001]; and defibrillation: [C: 157(140-254) vs. 6M: 138(107-158) vs. 3M: 115(101-119) vs. 2M: 109(98-129); p < 0.001]. A composite outcome of key priorities, compressions within 20s, defibrillation within 180 s and use of a backboard, revealed improvement with more frequent training sessions: [C:5%(1/18) vs. 6M: 23%(4/17) vs. 3M: 56%(9/16) vs. 2M: 73%(11/15); p < 0.001]. CONCLUSION Results revealed short in-situ training sessions conducted every 3 months are effective in improving timely initiation of chest compressions and defibrillation in IHCA.

Simulated Pediatric Resuscitation Use for Personal Protective Equipment Adherence Measurement and Training During the 2009 Influenza (H1N1) Pandemic

Article-at-a-Glance Background Previous experience with simulated pediatric cardiac arrests (that is, mock codes) suggests frequent deviation from American Heart Association (AHA) basic and advanced life support algorithms. During highly infectious outbreaks, acute resuscitation scenarios may also increase the risk of insufficient personal protective equipment (PPE) use by health care workers (HCWs). Simulation was used as an educational tool to measure adherence with PPE use and pediatric resuscitation guidelines during simulated cardiopulmonary arrests of 2009 influenza A patients. Methods A retrospective, observational study was performed of 84 HCWs participating in 11 in situ simulations in June 2009. Assessment included (1) PPE adherence, (2) confidence in PPE use, (3) elapsed time to specific resuscitation maneuvers, and (4) deviation from AHA guidelines. Results Observed adherence with PPE use was 61% for eye shields, 81% for filtering facepiece respirators or powered air-purifying respirators, and 87% for gown/gloves. Use of a “gatekeeper” to control access and facilitate donning of PPE was associated with 100% adherence with gown and respirator precautions and improved respirator adherence. All simulations showed deviation from pediatric basic life support protocols. The median time to bag-valve-mask ventilation improved from 4.3 to 2.7minutes with a gatekeeper present. Rapid isolation carts appeared to improve access to necessary PPE. Confidence in PPE use improved from 64% to 85% after the mock code and structured debriefing. Conclusions Large gaps exist in the use of PPE and self-protective behaviors, as well as adherence to resuscitation guidelines, during simulated resuscitation events. Intervention opportunities include use of rapid isolation measures, use of gatekeepers, reinforcement of first responder roles, and further simulation training with PPE.

Integration of in-hospital cardiac arrest contextual curriculum into a basic life support course: a randomized, controlled simulation study

OBJECTIVE The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS). DESIGN This study is a prospective, randomized, controlled curriculum evaluation. SETTING Johns Hopkins Medicine Simulation Center. SUBJECTS One hundred twenty-two first year medical students were divided into fifty-nine teams. INTERVENTION HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP). MEASUREMENTS The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation. MAIN RESULTS Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p<0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p<0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p<0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p<0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p<0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p<0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p<0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p<0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p<0.001]. CONCLUSION A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study.

Objectives: To determine whether time to prepare IV medications for hyperkalemia varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data support the Advanced Cardiac Life Support recommended sequence. Design: Prospective randomized simulation-based study. Setting: Single pediatric tertiary medical referral center. Subjects: Pediatric nurses and adult or pediatric pharmacists. Interventions: Subjects were randomized to prepare medication doses for one of four medication sequences and stratified by one of three weight categories representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and 50 kg. Using provided supplies and dosing references, subjects prepared doses of calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with dextrose. Because insulin and dextrose are traditionally prepared and delivered together, they were analyzed as one drug. Subjects preparing medications were video-recorded for the purpose of extracting timing data. Measurements and Main Results: A total of 12 nurses and 12 pharmacists were enrolled. The median (interquartile range) total preparation time for the three drugs was 9.5 minutes (6.4–13.7 min). Drugs were prepared significantly faster for larger children (50 kg, 6.8 min [5.6–9.1 min] vs 20 kg, 9.5 min [8.6–13.0 min] vs 4 kg, 16.3 min [12.7–18.9 min]; p = 0.001). Insulin with dextrose took significantly longer to prepare than the other medications, and there was no difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8–2.6] vs calcium chloride, 2.1 [1.2–3.1] vs calcium gluconate, 2.4 [2.1–3.0] vs insulin with dextrose, 5.1 min [3.7–7.7 min], respectively; p < 0.001). Forty-two percent of subjects (10/24) made at least one dosing error. Conclusions: Medication preparation for hyperkalemia takes significantly longer for smaller children and preparation of insulin with dextrose takes the longest. This study supports Pediatric Advanced Life Support guidelines to treat hyperkalemia during pediatric cardiac arrest similar to those recommended per Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; and third, insulin with dextrose).

Exploration of the impact of a voice activated decision support system (VADSS) with video on resuscitation performance by lay rescuers during simulated cardiopulmonary arrest

Aim To assess whether access to a voice activated decision support system (VADSS) containing video clips demonstrating resuscitation manoeuvres was associated with increased compliance with American Heart Association Basic Life Support (AHA BLS) guidelines. Methods This was a prospective, randomised controlled trial. Subjects with no recent clinical experience were randomised to the VADSS or control group and participated in a 5-min simulated out-of-hospital cardiopulmonary arrest with another ‘bystander’. Data on performance for predefined outcome measures based on the AHA BLS guidelines were abstracted from videos and the simulator log. Results 31 subjects were enrolled (VADSS 16 vs control 15), with no significant differences in baseline characteristics. Study subjects in the VADSS were more likely to direct the bystander to: (1) perform compressions to ventilations at the correct ratio of 30:2 (VADSS 15/16 (94%) vs control 4/15 (27%), p=<0.001) and (2) insist the bystander switch compressor versus ventilator roles after 2 min (VADSS 12/16 (75%) vs control 2/15 (13%), p=0.001). The VADSS group took longer to initiate chest compressions than the control group: VADSS 159.5 (±53) s versus control 78.2 (±20) s, p<0.001. Mean no-flow fractions were very high in both groups: VADSS 72.2% (±0.1) versus control 75.4 (±8.0), p=0.35. Conclusions The use of an audio and video assisted decision support system during a simulated out-of-hospital cardiopulmonary arrest prompted lay rescuers to follow cardiopulmonary resuscitation (CPR) guidelines but was also associated with an unacceptable delay to starting chest compressions. Future studies should explore: (1) if video is synergistic to audio prompts, (2) how mobile technologies may be leveraged to spread CPR decision support and (3) usability testing to avoid unintended consequences.

Conducting multicenter research in healthcare simulation: Lessons learned from the INSPIRE network

Simulation-based research has grown substantially over the past two decades; however, relatively few published simulation studies are multicenter in nature. Multicenter research confers many distinct advantages over single-center studies, including larger sample sizes for more generalizable findings, sharing resources amongst collaborative sites, and promoting networking. Well-executed multicenter studies are more likely to improve provider performance and/or have a positive impact on patient outcomes. In this manuscript, we offer a step-by-step guide to conducting multicenter, simulation-based research based upon our collective experience with the International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE). Like multicenter clinical research, simulation-based multicenter research can be divided into four distinct phases. Each phase has specific differences when applied to simulation research: (1) Planning phase, to define the research question, systematically review the literature, identify outcome measures, and conduct pilot studies to ensure feasibility and estimate power; (2) Project Development phase, when the primary investigator identifies collaborators, develops the protocol and research operations manual, prepares grant applications, obtains ethical approval and executes subsite contracts, registers the study in a clinical trial registry, forms a manuscript oversight committee, and conducts feasibility testing and data validation at each site; (3) Study Execution phase, involving recruitment and enrollment of subjects, clear communication and decision-making, quality assurance measures and data abstraction, validation, and analysis; and (4) Dissemination phase, where the research team shares results via conference presentations, publications, traditional media, social media, and implements strategies for translating results to practice. With this manuscript, we provide a guide to conducting quantitative multicenter research with a focus on simulation-specific issues.