Pamela Aitchison

Development and evaluation of a simulation-based pediatric emergency medicine curriculum

Purpose The infrequency of severe childhood illness limits opportunities for emergency medicine (EM) providers to learn from real-world experience. Simulation offers an evidence-based educational approach to develop and practice clinical skills. Method This was a two-phase, randomized trial with a wait-list control condition. The development phase (2005–2006) involved systematic curriculum and rating checklist creation, producing a six-case, simulation-based curriculum linked to three evaluation cases. In the validation phase (2006–2007), the authors randomized 69 residents from two EM residencies to either an intervention group that received the curriculum one month before the first assessment of all participants or a wait-list control group that received the identical curriculum three months later. A final assessment of all residents followed one month after that. Two raters evaluated all residents. Primary outcome measures are percentages of items completed correctly. The authors assessed rater agreement using intraclass correlation (ICC) and compared group performance using mixed-model analysis of variance. Results ICCs surpassed 0.78. The instructional intervention produced a statistically significant effect for two of three evaluation cases for the validation phase of the study, a case × occasion interaction. Training year was significantly associated with better performance. In a multivariate analysis, training year and session correlated with score, but study group did not. Conclusions A one-day, simulation-based pediatric EM curriculum produced limited results. The evaluation approach is reasonable and reproducible for the population studied. Instructional dose strength and factors may have limited curriculum effectiveness. Focused, frequent, and effortful instructional interventions are necessary to achieve substantial performance improvements.

Comparison of checklist and anchored global rating instruments for performance rating of simulated pediatric emergencies.

Purpose: To compare the psychometric performance of two rating instruments used to assess trainee performance in three clinical scenarios. Methods: This study was part of a two-phase, randomized trial with a wait-list control condition assessing the effectiveness of a pediatric emergency medicine curriculum targeting general emergency medicine residents. Residents received 6 hours of instruction either before or after the first assessment. Separate pairs of raters completed either a dichotomous checklist for each of three cases or the Global Performance Assessment Tool (GPAT), an anchored multidimensional scale. A fully crossed person × rater × case generalizability study was conducted. The effect of training year on performance is assessed using multivariate analysis of variance. Results: The person and person × case components accounted for most of the score variance for both instruments. Using either instrument, scores demonstrated a small but significant increase as training level increased when analyzed using a multivariate analysis of variance. The inter-rater reliability coefficient was >0.9 for both instruments. Conclusions: We demonstrate that our checklist and anchored global rating instrument performed in a psychometrically similar fashion with high reliability. As long as proper attention is given to instrument design and testing and rater training, checklists and anchored assessment scales can produce reproducible data for a given population of subjects. The validity of the data arising for either instrument type must be assessed rigorously and with a focus, when practicable, on patient care outcomes.

Neonatal resuscitation guidelines

The following guidelines apply to infants in perinatal transition from intrauterine to extrauterine life as well as those that have concluded perinatal transition but require resuscitation during the early weeks to months of life. The goal of this article is to outline the most recent consensus guidelines for neonatal resuscitation and to summarize the level of evidence for the steps that constitute these guidelines. Nearly 1 in 10 newborns need some basic resuscitative measures to aid breathing at birth, but fewer than 1 in 100 require major resuscitations. Practitioners can rapidly assess the need for neonatal resuscitation by observing 3 vital characteristics of the birth:

Adult stroke summary.

Strokes are the third leading cause of death in the United States. The incidence of strokes in this country is staggering, with nearly 795,000 people suffering a new stroke or repeated stroke every year. Given the time-sensitive nature of treatment and the expertise needed to make these critical decisions, significant changes have been made to stroke care. Regionalization of stroke care was not widely considered prior to the National Institute of Neurological Disorders and the Stroke (NINDS) recombinant tissue plasminogen activator (rtPA) trial. The systems of care concept consist of healthcare providers’ first detection of strokes signs and symptoms and ultimately rapid admission to a stroke unit for definitive care. The ‘‘D’s of Stroke Care’’ define major steps in the diagnosis and treatment of strokes:

Growth of a Simulation Lab: Engaging the Learner Is Key to Success

igh-fidelity simulation (HFS) is an important adjunct to clinical training for eaching health care workers. Currently, the American College of Surgeons as created a multilevel certification for surgical simulation centers. The merican Society of Anesthesiologists Workgroup on Simulation Education as begun to characterize simulation centers for the purposes of “approval” s a site to provide continuing medical education credits. The Accreditation ouncil for Graduate Medical Education Residency Review Committee for mergency Medicine has determined that simulation may serve as an adjunct or the documentation of competencies. The Society for Academic Emerency Medicine’s Simulation Academy has recently made recommendations or accreditation and programmatic benchmarks for emergency medicine imulation. Since 2006, HFS has become increasingly integrated into ndergraduate and graduate medical educational curricula. The primary benefit of using HFS is that learners can practice medical ecision-making and procedures skills on simulated patients in an environent where the risk of error will not harm an actual patient. These echnologies were developed to practice skills without incurring risk: in the ilitary for war games exercises, in the aerospace industry for flight training f pilots and astronauts, and in the nuclear power industry to train personnel. ridging the gap between other industries and medicine, Gaba and DeAnda ioneered the use of simulation in anesthesia to train anesthesiologists. Simulation has also received favorable reviews as an effective model for eaching medicine because of its ability to allow learners of all levels to

Adult resuscitation summary.

Life support is a chain of events and therapies that follow the victim from the initial recognition of cardiac arrest to advanced in-hospital therapies following their resuscitation. The AHA has named this the ‘‘Chain of Survival.’’ Like any chain there are separate links, or steps, that must be connected by providers to form the chain from start to finish. To lean on the metaphor somewhat more, if any link in that chain is weak, or missing, the outcome for the patient will likely be less than what it could be, if all the links were strong. The following pages will go on to elucidate the links in the chain (both BLS and ACLS), and highlight many of the pertinent finer points that providers should be aware of. We will also specifically address the important changes from previous care recommendations. The first link in the chain of survival is immediate recognition of sudden cardiac arrest and activation of emergency response system (ERS). Upon witnessing an unresponsive or recently collapsed victim, providers should first ensure a safe scene by looking for obvious hazards, which may bring danger upon themselves. An unprepared rescuer can quickly become a second victim if an area is not properly secured. For example, moving a victim away from a busy intersection will delay the second link, but will be far safer than initiating that step near street traffic. Next, providers should check for response by stimulating the victim. Common and acceptable methods are verbal (shouting in the ear) and tactile (forceful sternal rub). Even after a normal response to stimulation, and certainly if the victim is unresponsive, providers should promptly activate the emergency response system (EMS). This can be done by a single provider with a phone, or by designating another bystander to call 911. In the situation that a lone rescuer finds the victim, it is recommended that 5 rounds of CPR be given prior to seeking out help if a phone is not on hand. The second link in the chain of survival is to provide early high-quality CPR (Fig. 1). There are different recommendations for lay providers and experienced healthcare professionals. If victim is unresponsive or not breathing normally (gasping), the lay provider should assume victim is in cardiac arrest. Lay rescuers should not perform pulse checks. After calling EMS, the rescuer should immediately begin CPR or prepare to receive instructions for CPR from the dispatcher. Lay rescuers should not provide rescue breaths unless asphyxiation is suspected. If asphyxiation is suspected, or if rescuer is trained, add rescue breaths to the chest compressions in a ratio of 30 compressions to 2 breaths. Lay rescuers should continue CPR until an automated external defibrillator (AED) arrives, the victim wakes up, or EMS personnel take over.

A review of cardiopulmonary resuscitation and its history

In 1768, the Dutch Humane Society was founded by physicians and laypeople to work together to assist victims of drowning. The society created and disseminated rules and methods of resuscitation. At that time, it was thought that victims of drowning died due to inhaled water. Initial resuscitation attempts focused on hanging the victim upside down or rolling them inverted on barrels. In 1889, Sir Henry Head developed the cuffed endotracheal tube. In 1895, Alfred Kirstein invented the laryngoscope in order to better visualize the trachea. Dr. Peter Safar, an anesthesiologist, in the mid-twentieth century investigated various techniques for airway management. He found that 50% of patients’ airways would be opened by a head tilt; the remaining 50% could be opened with either thrusting the mandible forward or the insertion of an oropharyngeal airway.

Pediatric resuscitation guidelines.

Cardiopulmonary resuscitation (CPR) providers should first assess the safety of the scene with regards to both patient and rescuer. Once the scene is determined to be safe, the need for resuscitation is addressed. Providers should assume that CPR is needed if the victim is unresponsive and is not breathing, or the patient is breathing irregularly. To check if the victim is responsive, ask the child if he/she is okay or call the child by name. The child is considered to be responsive if they answer, move, or moan. If the child is responsive, identify any injuries or trauma that may be present to determine if medical assistance is needed. If needed, the lone rescuer may leave the child to activate the emergency response system and should return as quickly as possible to check on the child’s condition. If bystanders are present, the rescuer should shout for help and ask the bystanders to alert emergency medical services (EMS). While awaiting the arrival of EMS, the responsive child should be left in the recovery position. In the case where no traumatic injury is identified, the child can be placed on his or her side.