Margarita Burmester

Initial experience with fenoldopam after cardiac surgery in neonates with an insufficient response to conventional diuretics.

Objective: Fenoldopam, a selective dopamine-1 receptor agonist, causes systemic vasodilation and increased renal blood flow and tubular sodium excretion. We hypothesized that urine output would improve when fenoldopam was added to conventional diuretic therapy after neonatal cardiopulmonary bypass. Design: Retrospective cohort study using a time-series design. Setting: Pediatric cardiac intensive care unit. Patients: All neonates who received fenoldopam to promote diuresis after cardiac surgery requiring cardiopulmonary bypass from February 2002 through December 2004. Interventions: Fenoldopam infusion for inadequate urine output despite conventional diuretics. Measurements: Demographics, diagnostic information, and surgical procedures were recorded. Urine output, fluid balance, inotrope scores, diuretic doses, and other clinical variables that may influence diuresis were recorded for the 24-hr period immediately preceding fenoldopam initiation and during the initial 24 hrs of drug administration. Main Results: A total of 25 neonates received fenoldopam to promote diuresis after the modified Norwood (n = 14), arterial switch (n = 4), or other operations (n = 7). Heart rate, conventional diuretic dosing, and fluid intake were similar during the 24-hr periods of conventional therapy and fenoldopam use (p = not significant for all), whereas inotrope scores decreased during the study (p = .021). There was a small but statistically significant increase in blood pressure during the 48-hr study period. Median urine output was 3.6 mL·kg−1·hr−1 (range, 0.2–7.2 mL·kg−1·hr−1) during the 24-hr period of conventional therapy and 5.8 mL·kg−1·hr−1 (range, 1.6–11.7 mL·kg−1·hr−1) during the initial 24 hrs of fenoldopam administration (Wilcoxons signed-rank test, p = .001). Conclusions: Fenoldopam may improve urine output in neonates who are failing to achieve an adequate negative fluid balance despite conventional diuretic therapy after cardiac surgery and cardiopulmonary bypass. This study is limited by its retrospective design and the possibility that urine output improved spontaneously during the treatment period. A randomized, placebo-controlled clinical trial will be required to confirm these findings.

Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework

BackgroundAs a conceptual review, this paper will debate relevant learning theories to inform the development, design and delivery of an effective educational programme for simulated team training relevant to health professionals.DiscussionKolb’s experiential learning theory is used as the main conceptual framework to define the sequence of activities. Dewey’s theory of reflective thought and action, Jarvis modification of Kolb’s learning cycle and Schön’s reflection-on-action serve as a model to design scenarios for optimal concrete experience and debriefing for challenging participants’ beliefs and habits. Bandura’s theory of self-efficacy and newer socio-cultural learning models outline that for efficient team training, it is mandatory to introduce the social-cultural context of a team.SummaryThe ideal simulated team training programme needs a scenario for concrete experience, followed by a debriefing with a critical reflexive observation and abstract conceptualisation phase, and ending with a second scenario for active experimentation. Let them re-experiment to optimise the effect of a simulated training session. Challenge them to the edge: The scenario needs to challenge participants to generate failures and feelings of inadequacy to drive and motivate team members to critical reflect and learn. Not experience itself but the inadequacy and contradictions of habitual experience serve as basis for reflection. Facilitate critical reflection: Facilitators and group members must guide and motivate individual participants through the debriefing session, inciting and empowering learners to challenge their own beliefs and habits. To do this, learners need to feel psychological safe. Let the group talk and critical explore. Motivate with reality and context: Training with multidisciplinary team members, with different levels of expertise, acting in their usual environment (in-situ simulation) on physiological variables is mandatory to introduce cultural context and social conditions to the learning experience. Embedding in situ team training sessions into a teaching programme to enable repeated training and to assess regularly team performance is mandatory for a cultural change of sustained improvement of team performance and patient safety.

Anti-inflammatory modalities: Their current use in pediatric cardiac surgery in the United Kingdom and Ireland*

Objective: To determine the use of anti-inflammatory therapies in infants and children undergoing cardiac surgery in the United Kingdom and Ireland. Design: Questionnaire survey. Subjects: All centers that undertake pediatric cardiac surgery in the United Kingdom and Ireland. Results: All centers use at least one anti-inflammatory therapy, with 46% of centers using more than one. Both modified ultrafiltration (80%) and steroids (80%) are widely used as anti-inflammatory strategies. Among centers that use steroids, dose, preparation, and timing of steroid administered was highly variable. Heparin-bonded circuits and aprotinin are infrequently used as anti-inflammatory techniques. Conclusion: Although anti-inflammatory interventions are believed to contribute to improved patient outcome following cardiopulmonary bypass, this survey has shown that there are still widespread variations in practice. Rather than reflecting poor clinical practice, we believe this reflects a lack of good evidence supporting clinical benefit.

Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review

Objective To assess the impact of service improvements implemented because of latent threats (LTs) detected during in situ simulation. Design Retrospective review from April 2008 to April 2015. Setting Paediatric Intensive Care Unit in a specialist tertiary hospital. Intervention Service improvements from LTs detection during in situ simulation. Action plans from patient safety incidents (PSIs). Main outcome measures The quantity, category, and subsequent service improvements for LTs. The quantity, category, and subsequent action plans for PSIs. Similarities between PSIs and LTs before and after service improvements. Results 201 Simulated inter-professional team training courses with 1,144 inter-professional participants. 44 LTs were identified (1 LT per 4.6 courses). Incident severity varied: 18 (41%) with the potential to cause harm, 20 (46%) that would have caused minimal harm, and 6 (13%) that would have caused significant temporary harm. Category analysis revealed the majority of LTs were resources (36%) and education and training (27%). The remainder consisted of equipment (11%), organizational and strategic (7%), work and environment (7%), medication (7%), and systems and protocols (5%). 43 service improvements were developed: 24 (55%) resources/equipment; 9 (21%) educational; 6 (14%) organizational changes; 2 (5%) staff communications; and 2 (5%) guidelines. Four (9%) service improvements were adopted trust wide. 32 (73%) LTs did not recur after service improvements. 24 (1%) of 1,946 PSIs were similar to LTs: 7 resource incidents, 7 catastrophic blood loss, 4 hyperkalaemia arrests, 3 emergency buzzer failures, and 3 difficulties contacting staff. 34 LTs (77%) were never recorded as PSIs. Conclusion An in situ simulation program can identify important LTs which traditional reporting systems miss. Subsequent improvements in workplace systems and resources can improve efficiency and remove error traps.

P58 Perceived improvement of non-technical skills and confidence after in-situ simulation emergency events and the effect of repeated training

Objective Non-technical skills are vital for successful management of emergencies by healthcare professionals working within interprofessional teams. In-situ simulation and crisis resource management (CRM) training using real clinical areas and teams can contribute to improved non-technical skills, and ultimately improved patient care and safety.1 The Simulated inter-Professional Team Training (SPRinT) programme runs in-situ simulation courses focusing on CRM and human factors with frontline interprofessional teams involved in the care of critically ill patients. We aimed to assess the impact of SPRinT courses and repeated training on participants’ perceived non-technical skills and confidence to attend future real events. Methods Retrospective review of SPRinT database and feedback questionnaires. Questions on course components and quality, and participants’ perception on themes including improvement of non-technical skills, realism of scenario, and usefulness for management of future real events were scored with a 0%–100%  scale. Data was described as median (IQR) and comparison between participants by number of previous SPRinT courses attended was performed using Dunn’s test with Sidak correction for pairwise comparison. Questionnaires are anonymous and part of an educational programme; therefore ethical approval was not required. Results 565 participants underwent 76 courses from April 2014 to April 2017 (mean 2 courses/month, 7 participants/course), and 93% (526) answered the questionnaire. Overall course rating was 90% (IQR 80%–100%), and realism of scenario’s environment and stress level were 80% (IQR 70%–90%) and 80% (IQR 65%–90%), respectively. Overall agreement for improved non-technical skills and increased confidence to manage future events was high (median 80%, IQR 70%–90% for both aspects). Agreement for providing safer patient care in the future was median 90% (IQR 80%–95%). 79% (416/526) of participants answered the question on repeated training. Those that underwent 3 or more courses reported a significant further improvement on: perceived non-technical skills; confidence to attend future clinical events; management of critical situations; and provision of safer patient care in the future (Table 1). Conclusion Participants perceive improved non-technical skills and confidence to attend future real events through SPRinT in-situ simulation courses. Further improvement is observed through repeated training, with three-course attendance being the cut-off to significantly improve most aspects of perceived non-technical skills. This is consistent with our previous publication2 and should be set as a standard to all staff participating in SPRinT courses. Further studies are required to investigate whether training intervals exert any influence on non-technical skills acquisition. References . Patterson MD, Geis GL, Falcone RA, et al. In situ simulation: Detection of safety threats and teamwork training in a high-risk emergency department. BMJ Qual Saf 2013;22:468–477. . Stocker M, Allen M, Pool N, et al. Impact of an embedded simulation team training programme in a paediatric intensive care unit: A prospective, single-centre, longitudinal study. Intensive Care Med 2012;38(1):9–04. Abstract P58 Table 1

0178 Simulated and anticipatory frontline education quality improvement project (SAFEQIP)

Background The benefits of education through simulation are augmented when coupled to quality improvement and educational initiatives by improving patient safety.1 We harnessed the strengths of simulation to develop a quality improvement project (SAFEQIP) aiming to improve anticipatory care, using role allocation through a multifaceted educational approach with the overarching goal to improve patient safety, staff education and team-working. Methodology planned In-situ Simulated inter-PRofessional Team (SPRinT) courses are embedded within PICU. Currently, a validated tool monitors participant self-evaluation of team-performance during these SPRinT courses, and during real resuscitations.2,3 The project will involve pre-allocation of roles during SPRinT courses, and role allocation during twice daily safety huddles of the arrest team, thereby providing roles prior to real and simulated arrests. A change in TeamMonitor2 scores and process measures will be assessed pre and post project implementation. Additionally a system has been created to disseminate learning events and latent threats from simulations to the wider team whilst ensuring a confidential, safe learning environment. This will also enable replication of successes by sharing and cascading Safety 2 events to frontline staff. Outcomes anticipated/to date Team-performance including role allocation has been scored by participating staff during real resuscitations since May 2014. Additional baseline data suggests most role allocation is performed during the arrest with no current pre-planning in place. Staff desire for anticipatory planning was strongly suggested from feedback from simulated and real events. Potential impact SAFEQIP could mitigate threats associated with ad-hoc team-building during resuscitations.Staff will be empowered to strategically plan prior to resuscitations and team-cohesiveness fostered. Learning is facilitated through sharing learning events. Patient outcome may benefit as pre-planning enables less hands-off time during chest compressions, decreased time to initiate crucial first treatments and improved leadership and communication.4 References Barton J, et al. Impact of multidisciplinary team training and high fidelity simulation in critical patient scenarios. Med Sci Educ 2013;23(3S):532–540 Stocker M, et al. Reliability of team-based self-monitoring in critical events: a pilot study. BMC Emerg Med 2013;13:22 Stocker M, et al. Impact of an embedded simulation team training programme in a paediatric intensive care unit: a prospective, single-centre, longitudinal study. Intensive Care Med. 2012;38(1):99–104 Fernandez Castelao E, et al. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. J Crit Care 2013;28:504–521

0160 A bespoke mobile trolley maximises the benefits of in-situ simulation training to improve patient safety

Background The Simulated Interprofessional Team Training programme, SPRinT, a validated in-situ simulation programme delivers point-of-care team-training to >180 staff annually. In-situ simulation provides an authentic learning experience, key to translation into real clinical practice. Benefits include system testing and improvement, latent threat identification and mitigation, and team-work training of real teams. Description of innovation To facilitate delivery of in-situ simulation throughout the hospital, (clinical areas in separate buildings), we decided to devise a mobile solution to minimise cost and set up time while maximising learning opportunities. Weinstock et al .1 highlighted the usefulness of a self-contained mobile cart in their paediatric unit. We have thus developed the bespoke SPRinT trolley enabling delivery of in-situ simulations to multiple sites throughout the hospital. Trolley cost = £ 2250. The secure compact design maximises portability and equipment safety. It offers elevated monitor facilities and a lockable full size CPU cupboard with earth bonded power. Outcomes/improvements Since introducing the SPRinT trolley, we have undertaken 95 SPRinT courses, training 711 members of hospital staff in 13 separate clinical locations including paediatric ICU/HDU/wards, adult ICU/HDU, outpatient clinics, theatres and recovery, catheter labs. 51 latent threats identified, resulting in 36 system quality improvements, 7 translated trust wide. Courses rated highly effective by >80% of participants. Take home message Using the SPRinT trolley, we have delivered the benefits of in-situ simulation-based team-training to more areas and staff than traditional simulation centre model oftraining, improving team performance and patient safety. Our trolley is cost effective, half We in stock trolley cost. Availability of new wireless manikins means some of our trolley features are being redesigned to keep pace with this innovative technology. The newly designed trolley aims to be reproducible and cost effective so that all hospitals will be able to transform their delivery of simulation based education and training. Reference Weinstock PH, et al. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatr Crit Care Med. 2009;10(2):176–181

0176 Perspectives of the value of interprofessional simulation training by participant background

Background Interprofessional simulation-based team training has been highlighted as a means to improve team performance,1 The Simulated interPRofessional Team training programme (SPRinT) has published data on the effectiveness of such programmes.2 We aimed to explore and understand participant perspectives on the value of the interprofessional aspects of simulation in our established programme. Methodology Participants attending SPRinT courses completed questionnaires on five common themes related to interprofessional simulation, indicating their level of agreement with statements. Results were analysed according to three general professional groups; nursing staff, medical staff and anaesthetists. Results Data was collected from 64 staff during 10 consecutive courses (91% response rate). The professional groups comprised 10 anaesthetists, 26 nursing staff and 22 medical staff. Medical and nursing groups indicated most of their previous simulation experience was with participants from mixed professional backgrounds (82% and 85% respectively). Anaesthetists indicated most previous simulation training had been with their own profession only (70%). All groups indicated similar levels of agreement that simulation improved their awareness of other professional’s roles (All groups: 100% agreement), helped break down workplace barriers (anaesthetists: 100%, nurses: 94%, medical: 91%) and improved their interprofessional team-working ability (anaesthetists: 100%, nurses: 100%, medical: 96%). Anaesthetists indicated that their specific technical training needs may be better met in solo profession simulation. This trend was not seen in the other groups. There was no distinct agreement amongst any groups as to whether participants felt more comfortable participating in groups of the same or multi-professional backgrounds. Conclusions Our results show all participants valued the opportunity for interprofessional simulation training, particularly in regards to increasing awareness of team members’ roles, breaking down barriers and improving working relationships. Anaesthetists highlighted the on-going need for single profession simulation when focusing on specialty-specific technical skills. Good team functioning has been demonstrated to improve patient outcome in critical incidents. Our results support the role for interprofessional simulation training in improving team cohesiveness. References A review of simulation-based interprofessional education. Clin Simulat Nurs 2011;7(4):117–126 Stocker M, et al. Impact of an embedded simulation team training programme in a paediatric intensive care unit: a prospective, single centre, longitudinal study. Intensive Care Med 2012;38(1):99–104

0196 A Feasibility Study of Parents’ Perceptions of close proximity in-situ Simulation within a Paediatric Cardiorespiratory Intensive Care Unit and Ward

Background Limited attention has been given to the challenge of providing family-centred care alongside simulations in the clinical area.1 The validated2 interprofessional in-situ SPRinT (Simulated Paediatric Resuscitation Team Training) programme delivers courses aimed at improving team performance and patient safety during critical events. We hypothesised that parents would actively support such training. Methodology A prospective, cross-sectional survey of parents of inpatient children present during a SPRinT course was carried out Mar–May 2014. 2 h SPRinT courses consisted of didactic crisis resource management teaching, simulated scenario, and video-assisted debriefing by trained interprofessional faculty. Scenarios derived from real events (eg emergency resternotomy, catastrophic haemorrhage) have a full responding team using real equipment, medications and arrest calls. Parents completed anonymous questionnaires assessing perception of SPRinT courses and their effect. 13 quantitative questions with 0–100% score indicating level of agreement with statements and qualitative response. Level of agreement: >80% score=strong; <20%=weak. Results 12 parents (6 fathers, 6 mothers; mean age 32 yrs, range 21–53 yrs) of 8 children (mean hospitalisation 47 days, range 1–270 days) returned questionnaires following 4 SPRinT courses. 1 questionnaire was excluded. 140/143 quantitative questions answered. Strong mean level of agreement scores were reported for: increased confidence in staff when they rehearse emergencies (97.3%), training should occur in all PICUs (97.3%), simulation may help staff provide safer care (96.4%). Weak mean level of agreement scores were reported for: perception of in-situ simulation to be disruptive/intimidating (4%), emergencies should be rehearsed elsewhere (5.5%), simulations upset me due to reminding me of what could happen to my child (19.1%), emergency simulations make me feel additional anxiety (19.1%). Qualitative analysis: “have seen the real thing on PICU, training definitely pays off”. Conclusions Parents felt simulations should occur in PICU, some reported mild increases in anxiety. Further research is required to determine specific provisions and information to mitigate anxiety. References Patterson MD, Blike GT, Nadkarni VM. In Situ Simulation: Challenges and Results. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug Stocker M, Allen M, Pool N, et al. Impact of an embedded simulation team training programme in a paediatric intensive care unit: a prospective, single-centre, longitudinal study. Intensive Care Med. 2012;38(1):99–104