Judy L. LeFlore

Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing: A Multicenter Randomized Trial

IMPORTANCE Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings. OBJECTIVE To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. DESIGN Prospective, randomized, factorial study design. SETTING The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing. PARTICIPANTS We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups. INTERVENTION Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators. MAIN OUTCOMES AND MEASURES Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC). RESULTS There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes. CONCLUSIONS AND RELEVANCE The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience.

Background: There are no reports in the literature that compare instructor-modeled learning to self-directed learning when simulation is used. Therefore, no evidence exists to know which approach is superior. This study aims to test the hypothesis that instructor-modeled learning is more effective compared with self-directed learning during a simulated clinical experience. Methods: This is a descriptive pilot study to compare instructor-modeled learning with self-directed learning during a clinical simulated experience. Four evaluation tools were used at three time points to evaluate knowledge, self-efficacy (self confidence), and behaviors. Results: Sixteen students participated. There were no statistically significant differences between the groups on the Knowledge Assessment Test. There were significant differences between the groups in the Self-Efficacy Tool (SET) at three times (time 1: P = 0.006, time 2: P = 0.008, time 3: P = 0.012). The only significance between the groups on the Technical Evaluation Tool was time to start Albuterol. The Behavioral Assessment Tool (BAT) showed significant differences between the groups in 8 out of 10 components of the tool. A strong correlation was observed between the overall score of the BAT and the SET Score. Conclusion: Although the small sample size prohibits definitive conclusions, the data suggest that instructor-modeled learning may be more effective than self-directed learning for some aspects of learning during a clinical simulated experience.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.

Background: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. Methods: A survey was conducted at the 19th Annual Children’s National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. Results: Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. Conclusion: Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Playing it safe: simulated team training in the OR.

Health care professionals are expected to make prompt, accurate decisions in life-threatening emergency situations in the OR. Perioperative leaders are faced with the challenge of ensuring that OR team members are prepared to respond to potentially lethal emergencies, including rare and infrequent events. This article describes the importance of team training for all members of the OR team. The use of simulation is discussed as a tool to accomplish this goal. Steps for developing a simulation scenario are presented.

Capillary refill time is an unreliable indicator of cardiovascular status in term neonates.

PURPOSEDecisions regarding the need for volume replacement in neonates often are made in the immediate newborn period. Capillary refill time (CRT) is used as an indicator of circulatory status; however, recent data show that CRT varies considerably with age, ambient and skin temperature, anatomical site of measurement, and duration of pressure. The purpose of this study was to (1) examine the relationship between CRT and heart rate (HR) and blood pressure (BP) in term neonates, and (2) evaluate the differences among CRT values measured at 3 body sites and with varying duration of cutaneous pressure. DESIGNThis was a prospective, cross-sectional, correlational study. SUBJECTSForty-two appropriate-weight-for-gestational-age (AGA) neonates with birthweights, (M = 3407; SD = ± 540 g), gestational ages (M = 39 weeks; SD = ± 1 week), and sex (21 males, 21 females). Infants had no history of perinatal distress or maternal chorioamnionitis. METHODSEach neonate was studied prospectively 1 to 4 hours after birth. The infants were clothed with only a diaper and evaluated on a radiant warmer bed set to achieve an axillary temperature of 36.5° to 37.0°C. Capillary refill time was measured with a digital stopwatch at 3 sites: volar surface of finger (F), plantar surface of heel (H), and lower sternum (St), using brief (1- to 2-second) and extended (3- to 4-second) pressure. Heart rate was auscultated and counted for 60 seconds, and BP was measured by oscillometry. Relationships among variables were assessed by Pearson correlation coefficient, analysis of variance, and multiple regression analysis. The Bonferroni correction for multiple comparisons was applied. MAIN OUTCOME MEASURESCapillary refill time, blood pressure, and heart rate. PRINCIPAL RESULTSThere was no significant site variation for CRT for either brief (2.4 ± 0.6 to 2.9 ± 1.0 seconds) or extended (3.8 ± 0.8 to 4.3 ± 0.8 seconds) pressure. However, regardless of site, CRT was greater when extended versus brief pressure was used (P < 0.001). There were no significant correlations between HR and CRT. There was a moderate, direct relationship between BP and CRT observed in the following anatomic sites: (1) sternum/extended pressure and systolic BP (SBP), diastolic BP, and mean BP (r = 0.35, P = 0.02; r = 0.49, P = 0.001; and r = 0.43, P = 0.005, respectively); (2) sternum/brief pressure and SBP (r = 0.31, P = 0.05); and (3) finger/extended pressure and SBP (r = 0.30, P = 0.05). CONCLUSIONSAn unanticipated moderate, direct correlation between BP and CRT was observed; prolongation of CRT occurred with elevated blood pressure. This finding may have been secondary to increased circulating vasoactive substances in the newborn period; measurement of these substances was beyond the scope of this study. In addition, CRT was highly dependent on the duration of cutaneous pressure, regardless of the site. These 2 findings indicate that CRT may be an unreliable indicator of cardiovascular status in the term neonate during the first 4 hours after birth.

EXPRESS--Examining Pediatric Resuscitation Education Using Simulation and Scripting. The birth of an international pediatric simulation research collaborative--from concept to reality.

Over the past decade, medical simulation has evolved into an essential component of pediatric resuscitation education and team training. Evidence to support its value as an adjunct to traditional methods of education is expanding; however, large multicenter studies are very rare. Simulation-based researchers currently face many challenges related to small sample sizes, poor generalizability, and paucity of clinically proven and relevant outcome measures. The Examining Pediatric Resuscitation Education Using Simulation and Scripting (EXPRESS) pediatric simulation research collaborative was formed in an attempt to directly address and overcome these challenges. The primary mission of the EXPRESS collaborative is to improve the delivery of medical care to critically ill children by answering important research questions pertaining to pediatric resuscitation and education and is focused on using simulation either as a key intervention of interest or as the outcome measurement tool. Going forward, the collaborative aims to expand its membership internationally and collectively identify pediatric resuscitation and simulation-based research priorities and use these to guide future projects. Ultimately, we hope that with innovative and high-quality research, the EXPRESS pediatric simulation research collaborative will help to build momentum for simulation-based research on an international level.

Alternative educational models for interdisciplinary student teams.

Background: Few studies compare instructor-modeled learning with modified debriefing to self-directed learning with facilitated debriefing during team-simulated clinical scenarios. Objective: To determine whether self-directed learning with facilitated debriefing during team-simulated clinical scenarios (group A) has better outcomes compared with instructor-modeled learning with modified debriefing (group B). Methods: This study used a convenience sample of students. The four tools used assessed pre/post knowledge, satisfaction, technical, and team behaviors. Thirteen interdisciplinary student teams participated: seven in group A and six in group B. Student teams consisted of one nurse practitioner student, one registered nurse student, one social work student, and one respiratory therapy student. The Knowledge Assessment Tool was analyzed by student profession. Results: There were no statistically significant differences within each student profession group on the Knowledge Assessment Tool. Group B was significantly more satisfied than group A (P = 0.01). Group B registered nurses and social worker students were significantly more satisfied than group A (30.0 ± 0.50 vs. 26.2 ± 3.0, P = 0.03 and 28.0 ± 2.0 vs. 24.0 ± 3.3, P = 0.04, respectively). Group B had significantly better scores than group A on 8 of the 11 components of the Technical Evaluation Tool; group B intervened more quickly. Group B had significantly higher scores on 8 of 10 components of the Behavioral Assessment Tool and overall team scores. Conclusion: The data suggest that instructor-modeling learning with modified debriefing is more effective than self-directed learning with facilitated debriefing during team-simulated clinical scenarios.

Effectiveness of 2 methods to teach and evaluate new content to neonatal transport personnel using high-fidelity simulation.

Neonatal transport team members undergo initial and periodic training to ensure knowledge and performance competencies. Given that various methods can be employed in this effort, it is important to evaluate how well new knowledge is learned and applied by transport team members and assess learner satisfaction. Self-paced modular learning and expert-modeled learning using high-fidelity simulations (HFSs) are 2 teaching/learning/evaluation tools for content application for team members. This article describes 2 educational approaches using simulated scenarios and evaluations. These experiences occurred in 2006, summer I (self-paced modular learning) and in 2007 for the same participants, summer II (expert-modeled learning). A group of experienced nurses, respiratory therapists, emergency medical technicians, and paramedics participated. Satisfaction was measured using a 5-point Likert scale. Effectiveness of HFS was evaluated using the Technical Evaluation Tool. Behavioral performance was assessed using the Behavioral Assessment Tool. The Technical Evaluation Tool showed that expert-modeled learning using HFS as a teaching/ learning/evaluation tool for application of content was effective as self-paced modular learning. Experienced participants appear to be satisfied with the use of HFS scenarios.

Determinants of blood pressure in very low birth weight neonates: lack of effect of antenatal steroids

OBJECTIVES To define the range of normal blood pressures (BP) for very low birth weight (VLBW;</=1500 g) neonates and to study perinatal variables affecting BP measurements after birth, including the effects of antenatal steroids. STUDY DESIGN Antenatal steroids were rarely administered at Parkland Memorial Hospital before May 1994, permitting us to establish a cohort of VLBW neonates exposed to antenatal steroids [n=70, 1166+/-253 (S.D.) g, and 28.7+/-2.1 weeks] who were matched with neonates delivered during the prior year (n=46, 1100+/-241 g, 28.9+/-1.8 weeks). Maternal and neonatal charts were abstracted for pertinent data, and neonatal BP measurements (determined directly when an arterial catheter was available or indirectly by the oscillometric method) were extracted every 3 h for the first 12 h and every 6 h until 72 h postnatal. RESULTS Antenatal steroids did not affect BP immediately after birth or for the subsequent 72 h postnatal. Therefore, data from all neonates </=1500 g were combined and the pattern of BP change over 72 h postnatal assessed. Systolic, diastolic and mean BP increased (P<0.001) 33%, 44% and 38%, respectively, during the first 72 h. Although neonates weighing </=1000 g and 1001-1500 g demonstrated gradual increases (P<0.001) in systolic, diastolic and mean BP by 72 h, values were consistently lower (P<0.01) in neonates </=1000 g. Of interest, only 11 neonates (9.5%) were treated for clinical hypotension. CONCLUSIONS In VLBW neonates antenatal steroids do not modify BP measurements either immediately after birth or the 30-40% rise occurring in the first 72 h postnatal. Further, BP is developmentally regulated and is gestationally and birth weight dependent. These data provide additional insight into assessing the need for treating hypotension.

Can a virtual patient trainer teach student nurses how to save lives--teaching nursing students about pediatric respiratory diseases.

Introduction Virtual environments offer a variety of benefits and may be a powerful medium with which to provide nursing education. The objective of this study was to compare the achievement of learning outcomes of undergraduate nursing students when a virtual patient trainer or a traditional lecture was used to teach pediatric respiratory content. Methods This was a randomized, controlled, posttest design. A virtual pediatric hospital unit was populated with four virtual pediatric patients having different respiratory diseases that were designed to meet the same learning objectives as a traditional lecture. The study began in Spring 2010 with 93 Senior I, baccalaureate nursing students. Students were randomized to receive either a traditional lecture or an experience with a virtual patient trainer. Students’ knowledge acquisition was evaluated using multiple-choice questions, and knowledge application was measured as timeliness of care in two simulated clinical scenarios using high-fidelity mannequins and standardized patients. Results Ninety-three students participated in the study, of which 46 were in the experimental group that received content using the virtual patient trainer. After the intervention, students in the experimental group had significantly higher knowledge acquisition (P = 0.004) and better knowledge application (P = 0.001) for each of the two scenarios than students in the control group. Conclusions The purpose of this project was to compare a virtual patient trainer to a traditional lecture for the achievement of learning outcomes for pediatric respiratory content. Although the virtual patient trainer experience produced statistically better outcomes, the differences may not be clinically significant. The results suggest that a virtual patient trainer may be an effective substitute for the achievement of learning outcomes that are typically met using a traditional lecture format. Further research is needed to understand how best to integrate a virtual patient trainer into undergraduate nursing education.