Kristen Nelson

A multi-institutional high-fidelity simulation "boot camp" orientation and training program for first year pediatric critical care fellows.

Objective: Simulation training has been used to integrate didactic knowledge, technical skills, and crisis resource management for effective orientation and patient safety. We hypothesize multi-institutional simulation-based training for first year pediatric critical care (PCC) fellows is feasible and effective. Design: Descriptive, educational intervention study. Setting: The simulation facility at the host institution. Interventions: A multicentered simulation-based orientation training “boot camp” for first year PCC fellows was held at a large simulation center. Immediate posttraining evaluation and 6-month follow-up surveys were distributed to participants. Measurements and Main Results: A novel simulation-based orientation training for first year PCC fellows was facilitated by volunteer faculty from seven institutions. The two and a half day course was organized to cover common PCC crises. High-fidelity simulation was integrated into each session (airway management, vascular access, resuscitation, sepsis, trauma/traumatic brain injury, delivering bad news). Twenty-two first year PCC fellows from nine fellowship programs attended, and 13 faculty facilitated, for a total of 15.5 hours (369 person-hours) of training. This consisted of 2.75 hours for whole group didactic sessions (17.7%), 1.08 hours for a small group interactive session (7.0%), 4.67 hours for task training (30.1%), and 7 hours for training (45.2%) with high-fidelity simulation and crisis resource management. A “train to success” approach with repetitive practice of critical assessment and interventional skills yielded higher scores in training effectiveness in the end-of-course evaluation. A follow-up survey revealed this training was highly effective in improving clinical performance and self-confidence. Conclusions: The first PCC orientation training integrated with simulation was effective and logistically feasible. The train to success concept with repetitive practice was highly valued by participants. Continuation and expansion of this novel multi-institutional training is planned.

A national survey of American Pediatric Anesthesiologists: patient-controlled analgesia and other intravenous opioid therapies in pediatric acute pain management.

BACKGROUND: The influence of patient characteristics, institutional demographics, and published practice guidelines on the provision of IV opioid analgesia, particularly as delivered through a patient-controlled analgesia (PCA) delivery device, to pediatric patients is unknown. METHODS: We sent a national, web-based, descriptive survey of pediatric pain management practice to select members of the Society for Pediatric Anesthesia to assess institutional demographics, availability and implementation of IVPCA and PCA by proxy, and recalled occurrence of serious and life-threatening opioid-related side effects. RESULTS: Data from respondents at 252 institutions throughout the United States were collected and analyzed. Sixty-nine percent of respondents practiced in a childrens hospital or childrens center within a general hospital, and 51% of institutions had a pediatric pain service. Virtually all pediatric pain services (91%) were administered by departments of anesthesiology. Pediatric pain service availability correlated with the number of pediatric beds. IVPCA was available to pediatric patients at 96% of institutions surveyed, whereas IVPCA by proxy was available at only 38%. Eleven percent of respondents reported that their hospital no longer provided IVPCA by proxy as a result of the 2004 Joint Commission on Accreditation of Hospitals Sentinel Event Warning. Instructional material concerning IVPCA was provided to patients or their families by 40% of institutions. IVPCA orders were handwritten by 55% of respondents, despite 39% having computerized provider order entry systems. Ninety percent of respondents reported using pulse oximetry monitoring when patients were administered IVPCA. Forty-two respondents recalled patients having received naloxone to counteract the cardiopulmonary side effects of opioids during the year before receipt of the survey. Eight respondents recalled patient deaths having occurred over the past 5 years in patients receiving IVPCA, IVPCA by proxy, and continuous non-IVPCA opioid infusions. CONCLUSIONS: Although IVPCA was available to pediatric patients at most institutions surveyed, prescribing practices and supervision of pediatric pain management were influenced by patient characteristics, institutional demographics, and published national guidelines. Recalled life-threatening events were reported in conjunction with all modes of opioid infusion therapy. Interventions that might diminish the incidence of adverse events but are not used to their fullest extent include improved education and implementation of systems designed to minimize human error involved in the prescribing of opioids. Providing a more accurate accounting of complications would require institutions to participate in a prospective data-collecting consortium designed to track both the incidence of therapy and associated complications.

The use of cognitive aids during simulated pediatric cardiopulmonary arrests

Background: Management of pediatric cardiopulmonary arrest (CPA) is challenging because of the low volume of experience of most pediatric health care providers. Use of cognitive aids may assist in making rapid decisions in these crises; however, there are no known published reports on whether these aids are actually used during arrest management and whether they impact quality of care. Methods: Sixty pediatric residents participated in individual simulated CPA scenarios, which involved pulseless ventricular tachycardia and pulseless electrical activity. Our primary outcome measure was the proportion of pediatric residents who used cognitive aids during simulated CPAs. Secondary outcome measures were to quantify 1) type of aids used, 2) category of use, and 3) human errors made during resuscitation efforts. Results: Eighty-five percent of residents voluntarily used a cognitive aid to assist in managing simulated pediatric CPAs. The most commonly used aids were an American Heart Association Pediatric Advanced Life Support aid and an institutionally created aid. Forty-three of 51 (84.3%) and 23 of 46 (60.5%) residents used these aids for assistance with the pulseless ventricular tachycardia and pulseless electrical activity algorithm, respectively. Unfortunately, 13 of 51 (25.5%) residents chose the incorrect treatment algorithm, resulting in inappropriate management. Conclusion and Application: Although the majority of residents chose to use cognitive aids for assistance, errors in management were common. Further study is required to determine whether these errors are associated with cognitive aid design flaws and whether improving their design through human factors research can help minimize errors in Basic and Advanced Life Support, ultimately improving patient outcomes.

Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario

Introduction: Supraventricular tachycardia (SVT) is the most frequent tachydysrhythmia in children. SVT with hemodynamic compromise should be terminated by immediate electrical cardioversion. Study objectives were to: (1) establish time to recognition and cardioversion of simulated unstable SVT; and (2) document delays and mistakes made during cardioversion. Methods: Ten teams of pediatric residents were presented with an unresponsive “patient” (Laerdal SimMan) in unstable SVT. Actions of team members and simulator timestamps of key events were recorded. A retrospective review of events and time logs was performed with primary outcome measure of time to successful cardioversion. Results: Median time to cardioversion was 8.9 minutes (range, 5.3 minutes to unsuccessful scenario terminated at 15 minutes). In 20% of scenarios, the patient was never cardioverted. Ninety percent of teams administered adenosine, but 44% of attempts demonstrated incorrect administration technique. Other maneuvers before cardioversion: 70% administered fluid, 60% attempted vagal maneuvers, 30% requested electrocardiogram, 30% requested antiarrhythmics. In 20% of scenarios, the rhythm was misidentified. When cardioversion was performed, 25% failed to use gel, 37.5% failed to synchronize, 25% used inappropriate energy doses. In 60% of scenarios, no oxygen was administered. In 90% there was no assignment of Glasgow Coma Scale, and no assessment of mental status in 30%. In 60% perfusion was not assessed. Conclusions: Median time to cardioversion of 8.9 minutes is inconsistent with AHA recommendations for treatment of unstable SVT with “immediate cardioversion.” Delays were secondary to lack of recognition of “unstable” SVT, due to failure to assess perfusion and mental status. Errors encountered during simulation identify curriculum reform targets.

The daily goals communication sheet: a simple and novel tool for improved communication and care.

This tool directs the health care team to discuss specific goals of care and best-practice safety measures daily for each patient and to ensure goal understanding and implementation.

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.

933: DEVELOPMENT OF A PEDIATRIC TRANSPORT TRIAGE TOOL

Learning Objectives: A modified Pediatric Early Warning Score (PEWS) for transport has been successfully used to assess illness severity, but not to guide transport decision making. Many transport teams are composed of a group of providers with varied experience. In an effort to standardize triage practices, we developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of transport mode and team configuration in order to improve care for children during transport. Methods: PT3 was created for pediatric transport, incorporating objective evaluation of neurologic, cardiovascular and respiratory (NCR) systems along with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team configuration not captured by NCR systems alone. A scoring algorithm was developed to guide transport mode and team configuration. Transport data were collected before and after PT3 initiation at a single tertiary center over an 18 month period. Transport mode, team configuration, complications during transport and disposition after transport [pediatric emergency department (PED), direct admission to pediatric ward or ICU (PICU)] were recorded. Results: We reviewed 4,391 inbound pediatric transport calls. Mean number of monthly transport calls (p=0.2) and initial patient disposition (PED p=0.2, PICU p=0.65) were not significantly different preand post-PT3 implementation. There were no differences in mean number of monthly medic (p=0.26), nurse (p=0.36), and physician level (p=0.49) calls, nor in transport mode (ground p=0.16, air p=0.5) utilized preand post-PT3. Need to upgrade team configuration or mode during transport was uncommon and not significantly different in preand post-PT3. No adverse patient safety events occurred with PT3 use. Conclusions: PT3 represents an objective triage tool to reduce variability in transport planning. PT3 did not result in increased resource utilization, or frequency of observed adverse outcomes. Transport teams with various staffing options and multiple modes of transport may benefit from such an objective assessment tool.

393: ACQUIRED ANTITHROMBIN DEFICIENCY IN PEDIATRIC CRITICAL ILLNESS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) solid tumors: 18%, Hemophagocytic lympho-histiocytosis: 14%); Non-Malignancy (immune dysregulation: 20%, bone marrow failure: 13%). Reasons for decompensation were: Respiratory42%, Cardiac15%, Neurologic16% and Multifactorial27%. Interventions needed were: ICU transfer68%, ventilation26%, hemodynamic support29% and invasive procedures (chest tubes, dialysis, biopsies etc.)35%. Deaths occurred in 31(54%) patients with 21(37%) deaths within 30 days after RR events. The median times from BMT and RR to death were 101 days and 13 days respectively. Comparison between survivors (S) and non-survivors (NS): 1) Reason for BMT: Malignancy-S:67%, NS:77%; NonmalignancyS:33%, NS:23% [p=0.11]; 2) BM donor source: AllogenicS:64%, NS:91%; AutologousS:20%, NS:5%; Cord bloodS:16%, NS:4% [p=0.01]; 3) ICU therapies: VentilationS:8%, NS: 39%; Hemodynamic supportS:20%, NS:38%; Invasive proceduresS:5%, NS:37% [p=0.01]. Conclusions: Respiratory decompensation was the most common etiology for Rapid Response in BMT patients. Mortality was high and was proximate to RR event but distant (beyond 90 days) from BMT. Non-survivors were significantly more likely to have received Allogenic BMT and significantly needed more ICU therapies like ventilation, hemodynamic support and invasive procedures.

94: PHASE OF CARE MORTALITY ANALYSIS FOR A PEDIATRIC CARDIOTHORACIC SURGICAL POPULATION

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) HAS-BLED score was 3. Gastrointestinal and intracranial bleeds occurred in 63% and 27% of patients, respectively. Rivaroxaban doses were excessive based on renal function in 35% of patients. Concurrent antiplatelet medications were prescribed in 70% of patients, with 10% receiving dual antiplatelet therapy. Two patients had a periprocedural/medication reconciliation error prior to the bleeding event, 10% had an invasive procedure within 7 days of the bleed, and 5% of patients were given rivaroxaban with concerns of bleeding. Nearly 50% of patients spent time in the ICU post-bleed. Bleed management consisted of a procedure/surgery in 18%, PRBC in 73%, FFP in 20%, and hemostatic agent use in 35% of patients. Anticoagulation was held at discharge in 76% of patients. Ten percent of patients were made hospice or palliative care. In-hospital mortality was 10%. Conclusions: Patients experiencing a rivaroxaban major bleed in practice were elderly and often on antiplatelet therapy. More than 25% of all major bleeds were intracranial. Hemostatic agents were administered to over one-third of patients. In-hospital mortality was 10%. Anticoagulation therapy remained held at discharge in the majority of patients.