Kevin Roy

Use of an expert concept map as an advance organizer to improve understanding of respiratory failure

Background: Helping novices transition toward expertise requires “meaningful” learning. Advance organizers are educational tools which help connect prior knowledge with new information, a critical step in making learning meaningful. Concept maps visually represent knowledge organization and can serve as advance organizers enabling deeper and more meaningful learning while enhancing knowledge integration. Aim: To compare respiratory failure understanding of resident physicians instructed, using an expert concept map advance organizer with learners receiving traditional didactic teaching. Methods: Residents were randomized by month of service to receive either a control lecture or a session using an expert concept map as an advanced organizer. Participants completed three concept maps; pre-education (CM1), immediately post-education (CM2), and 1 week later (CM3). Concept maps were scored using a standardized structural scoring method. Results: Forty-six pediatric residents (23 control and 23 experimental) participated. To account for repeated measures within subjects, the generalized estimating equations method compared concept map improvement between groups. The experimental group improved significantly more than controls (CM1–CM2–CM3 p = 0.001; CM1–CM2 p = 0.001; and CM1–CM3 p = 0.017). Conclusions: Using an expert concept map as an advance organizer improves knowledge organization and integration while offering a tool to enhance deeper understanding of medical knowledge among resident physicians.

Pediatric residents experience a significant decline in their response capabilities to simulated life-threatening events as their training frequency in cardiopulmonary resuscitation decreases.

Objective: To determine the frequency of cardiopulmonary resuscitation education using high-fidelity patient simulators during pediatric residency training. Design: Randomized controlled trial. Setting: Suburban tertiary care childrens hospital residency training program. Subjects: Twenty-four second year pediatric residents. Interventions: Twenty-four second year pediatric residents were randomized into two study groups, 12 residents in each. Both groups completed a formal resuscitation training course utilizing lectures, skill stations, and six scenarios on high-fidelity patient stimulators. Group A was retested on three scenarios 4 months after training and group B was similarly retested 8 months after training. Measurements and Main Results: Time intervals from induction of a clinical problem to its definitive management were recorded for each resident. Residents were also asked to complete surveys following each episode of training and testing. The mean time intervals, for group A, to start effective bag mask ventilation and chest compressions in response to apnea and cardiac arrest were 17.75 secs (±3.39 secs) and 23.42 secs (±9.33 secs), respectively. These were significantly shorter than 32.7 secs (±18.6 secs) and 81.2 secs (±74.9 secs), for group B, respectively (p < .05). Residents in group A provided higher survey scores for their level of confidence in using cardiopulmonary resuscitation pharmacology than residents in group B did (p < .05). The two groups were no different in their response time to defibrillate or to start anti-arrhythmia medications for life-threatening arrhythmias and in their endotracheal intubation skills. Conclusions: Pediatric residents show a significantly slower response time to effectively manage episodes of apnea and cardiac arrest 8 months after their initial resuscitation training, when compared to 4 months after training. These results may indicate that residents require more frequent training than currently recommended.

Finding Diagnostic Errors in Children Admitted to the PICU.

Objectives: To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU. Design and Setting: The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four “high-risk” patient cohorts admitted to the PICU between June 2013 and December 2013. Patients: High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours. Interventions: Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians. Measurements and Main Results: Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2–17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% (&kgr;, 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26). Conclusions: The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children.

Implementation of a Standard Verbal Sign-Out Template Improves Sign-Out Process in a Pediatric Intensive Care Unit.

Abstract: Sign-out of patient data at change of shifts is vulnerable to errors that impact patient safety. Although sign-outs are complex in intensive care units (ICU), a paucity of studies exists evaluating optimal ICU sign-out. Our prospective interventional study investigated the use of a standard verbal template in a Pediatric ICU to improve the sign-out process. We designed and validated a survey tool to measure 10 items of optimal sign-out. The survey and analysis of sign-out information exchanged was performed pre- and postintervention. Forty-eight clinicians participated, with a survey response rate of 88% and 81% in the pre- and postintervention phases, respectively. Seventy-nine percent clinicians identified the need for sign-out improvement. Clinician satisfaction with sign-out increased postintervention (preintervention survey scores: 3.26 (CI: 3.09–3.43), postintervention 3.9 (CI: 3.76–4.04) [p < .01]). Three scorers analyzed the verbal and written sign-out content with good inter-rater reliability. After the intervention, sign-out content revealed increased patient identification, background description, account of system-based clinical details [p = .001] and notation of clinical details, code status, and goals [p < .002]. Interruptions decreased [p = .04] without any change in sign-out duration [p = .86]. The standard verbal template improved clinician satisfaction with sign-out, augmented the amount of information transferred and decreased interruptions without increasing the duration of sign-out.

A Qualitative Study Exploring Moral Distress Among Pediatric Resuscitation Team Clinicians: Challenges to Professional Integrity*

Objective: Our study objectives were to explore moral distress among pediatric team clinicians within the context of resuscitation experiences, and determine whether there were any distinctively ethical perspectives on moral distress that could be conceptualized as challenges to professional integrity, rather than to previously described psychological responses of clinicians. Design: Descriptive, exploratory qualitative study. Setting: A large tertiary pediatric academic hospital in Houston, TX. Subjects: Twenty-five PICU resuscitation team clinicians were interviewed from December 2012 to April 2013. Interventions: None. Measurements and Main Results: All clinicians reported experiencing moral distress during certain resuscitations. Twenty-one of 25 clinicians reflected and acknowledged that their sense of professional integrity had been challenged during those resuscitation events. Four main components of resuscitation experience that induced moral distress were identified: 1) experiences where there was lack of understanding of the big picture; 2) experiences where there was suboptimal team leadership; 3) experiences where there was variable meanings to the word “resuscitation”; and 4) experiences were there was uncertainty of role responsibility. Conclusions: The perception of moral distress exists among pediatric clinicians during resuscitations and could be conceptualized as challenges to professional integrity. This ethical framework offers an alternative approach to understanding and investigating the complex layers of moral distress.

1244: A NOVEL APPROACH TO CLASSIFYING AND MANAGING HIGH-ALARMING PATIENTS IN A CRITICAL CARE ENVIRONMENT

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) for untoward side effects; however, this worry may be alleviated by supportive literature. We evaluated the evidence behind off-label medication use by determining the presence of published guideline support. Secondly, we compared graded recommendations in guidelines to strength of evidence ratings provided in an online tertiary resource DRUGDEX. Methods: Off-label medication use was identified prospectively over three months in medical ICUs in three academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website in order to determine the presence of guideline support for the off-label use identified in the three ICUs. Data collection included authors of the guideline, the grading method utilized, the grade given to the medication and the respective indication, and the definition provided for the grading method. DRUGDEX was also searched for strength of evidence ratings to serve as a comparator. Results: 287 off-label medication indication searches resulted in the detection of 253 guidelines for 56% (144/287) of indications. 101 indications had one guideline identified, 42 had two guidelines, and 18 had ≥3 guidelines associated with the medication and indication. Of the guidelines available, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, while 33% (47/144) of the gradings matched the online database. Conclusions: Since most off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines in order to inform off-label medication use. Future medication safety studies evaluating off-label use may also benefit from stratification based on guideline evidence. Furthermore, a considerable amount of off-label medication use lacks FDA approval and supporting evidence that may lead to inappropriate use and adverse events.