Melinda Fiedor Hamilton

Part 16: Education, Implementation, and Teams 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Optimizing the links in the Chain of Survival improves outcomes and saves lives. The use of evidence-based education and implementation strategies will allow organizations and communities to strengthen these links in the most effective and efficient manner.

Part 12: Education, Implementation, and Teams

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Precourse Preparation”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

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.

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments

Importance The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described. Objective To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures. Design, Setting, and Participants This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest). Main Outcomes and Measures A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS. Results Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001). Conclusions and Relevance This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.

Clinician Attitudes Toward Adoption of Pediatric Emergency Telemedicine in Rural Hospitals.

Objective Although there is growing evidence regarding the utility of telemedicine in providing care for acutely ill children in underserved settings, adoption of pediatric emergency telemedicine remains limited, and little data exist to inform implementation efforts. Among clinician stakeholders, we examined attitudes regarding pediatric emergency telemedicine, including barriers to adoption in rural settings and potential strategies to overcome these barriers. Methods Using a sequential mixed-methods approach, we first performed semistructured interviews with clinician stakeholders using thematic content analysis to generate a conceptual model for pediatric emergency telemedicine adoption. Based on this model, we then developed and fielded a survey to further examine attitudes regarding barriers to adoption and strategies to improve adoption. Results Factors influencing adoption of pediatric emergency telemedicine were identified and categorized into 3 domains: contextual factors (such as regional geography, hospital culture, and individual experience), perceived usefulness of pediatric emergency telemedicine, and perceived ease of use of pediatric emergency telemedicine. Within the domains of perceived usefulness and perceived ease of use, belief in the relative advantage of telemedicine was the most pronounced difference between telemedicine proponents and nonproponents. Strategies identified to improve adoption of telemedicine included patient-specific education, clinical protocols for use, decreasing response times, and simplifying the technology. Conclusions More effective adoption of pediatric emergency telemedicine among clinicians will require addressing perceived usefulness and perceived ease of use in the context of local factors. Future studies should examine the impact of specific identified strategies on adoption of pediatric emergency telemedicine and patient outcomes in rural settings.

Development and validation of a multiple choice examination assessing cognitive and behavioural knowledge of pediatric resuscitation: A report from the EXPRESS pediatric research collaborative

INTRODUCTION Assessing the knowledge of Pediatric Advanced Life Support (PALS) based learning objectives of medical trainees is an important evaluation component for both residency programs and for research studies. In this study, a multiple-choice question (MCQ) examination was developed and validated for use in a larger pediatric simulation resuscitation study (EXPRESS study). METHODS Experts in pediatric resuscitation developed two MCQ exams using a set of pre-determined learning objectives. After a single center pilot, the exam was used as an assessment of cognitive skills in the EXPRESS study, a multicenter trial examining the use of scripted debriefing and high-fidelity simulation in pediatric resuscitation education. Results from the MCQ in the pre-intervention phase of the EXPRESS study were used to assess the reliability and validity of the MCQ examination. In addition, an Exploratory Factor Analysis (EFA) was carried to assess the underlying structure of the PALS-based learning objectives. RESULTS 435 health care professionals completed the MCQ examination with an average score of 69.3%. Significantly higher examination results were seen in physicians vs. non-physicians, senior vs. junior physicians and participants with up-to-date PALS certification. The EFA results indicated four distinct categories of items were assessed. CONCLUSION This short MCQ examination demonstrated reasonable reliability and construct validity. It may be useful to assess pediatric resuscitation knowledge in future studies or courses.

Improving outcomes after pediatric cardiac arrest – the ICU-Resuscitation Project: study protocol for a randomized controlled trial

BackgroundQuality of cardiopulmonary resuscitation (CPR) is associated with survival, but recommended guidelines are often not met, and less than half the children with an in-hospital arrest will survive to discharge. A single-center before-and-after study demonstrated that outcomes may be improved with a novel training program in which all pediatric intensive care unit staff are encouraged to participate in frequent CPR refresher training and regular, structured resuscitation debriefings focused on patient-centric physiology.Methods/designThis ongoing trial will assess whether a program of structured debriefings and point-of-care bedside practice that emphasizes physiologic resuscitation targets improves the rate of survival to hospital discharge with favorable neurologic outcome in children receiving CPR in the intensive care unit. This study is designed as a hybrid stepped-wedge trial in which two of ten participating hospitals are randomly assigned to enroll in the intervention group and two are assigned to enroll in the control group for the duration of the trial. The remaining six hospitals enroll initially in the control group but will transition to enrolling in the intervention group at randomly assigned staggered times during the enrollment period.DiscussionTo our knowledge, this is the first implementation of a hybrid stepped-wedge design. It was chosen over a traditional stepped-wedge design because the resulting improvement in statistical power reduces the required enrollment by 9 months (14%). However, this design comes with additional challenges, including logistics of implementing an intervention prior to the start of enrollment. Nevertheless, if results from the single-center pilot are confirmed in this trial, it will have a profound effect on CPR training and quality improvement initiatives.Trial registrationClinicalTrials.gov, NCT02837497. Registered on July 19, 2016.

Communication training for inter-specialty clinicians

Inter‐specialty clinicians often co‐lead family conferences for hospitalised patients. Families frequently report receiving different messages from different clinicians. We developed a communication training workshop that crosses disciplines and co‐trains clinicians in one setting to create a culture of delivering a unified message.

Optimizing RRSs Through Simulation

A recent report by the National Registry of Cardiopulmonary Resuscitation (NRCPR) of 207 hospitals within the U.S. revealed that the majority (86%) has an organized team to respond to in-hospital cardiac arrests.1 Despite the existence of these teams, there is mounting evidence that errors in the management of care for patients with in-hospital cardiac arrests and other medical crises may contribute to poor outcomes.2 – 8 Currently, no standards exist in terms of how such “code teams” are dispatched, how many members are on the team, or the team’s composition. There are even fewer reports regarding the make-up of Medical Emergency Teams (METs). Training to enhance the quality of care delivered by crisis teams in hospitals is essential. Although the composition of these two types of hospital teams varies from place to place, the principles of team training remain the same, and are reviewed in this chapter.