Roberta Hales

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.

Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit

Objective: Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. Design: Prospective, observational pilot study. Setting: Single tertiary childrens hospital pediatric intensive care unit. Subjects: Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. Interventions: A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. Measurements and Main Results: For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd). Conclusions: It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

Reliability and validity of a scoring instrument for clinical performance during Pediatric Advanced Life Support simulation scenarios

AIM To assess the reliability and validity of scoring instruments designed to measure clinical performance during simulated resuscitations requiring the use of Pediatric Advanced Life Support (PALS) algorithms. METHODS Pediatric residents were invited to participate in an educational trial involving simulated resuscitations that employ PALS algorithms. Each subject participated in a session comprised of four scenarios (asystole, dysrhythmia, respiratory arrest, shock). Video-recorded sessions were independently reviewed and scored by four raters using instruments designed to measure performance in terms of timing, sequence, and quality. Validity was assessed by two-factor analysis of variance with postgraduate year (PGY-1 versus PGY-2) as an independent variable. Reliability was assessed by calculation of overall interrater reliability (IRR) as well as a generalizability study to estimate variance components of individual measurement facets (scenarios, raters) and associated interactions. RESULTS 20 subjects were scored by four raters. Based on a two-factor ANOVA, PGY-2s outperformed PGY-1s (p<0.05); significant differences in difficulty existed between the four scenarios, with dysrhythmia scores being the lowest. Overall IRR was high (0.81) and most variance could be attributed to subject (17%), scenario (13%), and the interaction between subject and scenario (52%); variance attributable to rater was minimal (1.4%). CONCLUSIONS The instruments assessed in this study measure clinical performance during PALS scenarios in a reliable and valid manner. Measurement error could be minimized further through the use of additional scenarios but additional raters, for a given scenario, would not improve reliability. Further studies should assess validity of measurement with respect to actual clinical performance during resuscitations.

Effect of Cervical Spine Immobilization Technique on Pediatric Advanced Airway Management : A High-Fidelity Infant Simulation Model

Objective: Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator. Methods: A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded. Results: Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 ± 12.2 seconds in no physical protection, 33.0 ± 17.4 seconds in C-collar, and 33.0 ± 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 ± 2.56°) and C-collar (2.65 ± 1.79°) were significantly greater compared with 0.85 ± 1.05° in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001). Conclusions: In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

Assessing pediatric residents' clinical performance in procedural sedation: a simulation-based needs assessment.

Objectives Our primary objective in this study was to perform a needs assessment of clinical performance during simulated procedural sedation (PS) by pediatric residents. Our secondary objective was to describe reported experience and confidence with PS during pediatric residency. Methods In this prospective observational cohort study, pediatric residents completed a survey of 15 Likert-scaled items pertaining to confidence in PS, followed by performance of a standardized, video-recorded simulated PS complicated by an adverse event (AE): apnea and desaturation. Clinical performance was evaluated according to an expert consensus–derived checklist of critical tasks. The difference in reported confidence between postgraduate years (PGY) was assessed by one-way analysis of variance (ANOVA); clinical checklist items were quantified descriptively. Results A total of 35 PGY-1, 39 PGY-2, and 7 PGY-3 residents participated. The most frequently completed tasks by all residents are ensuring the cardiorespiratory monitor (73%) and connecting the oxygen tubing (70%) during the preparation phase and recognizing AE (97%) and administering oxygen (95%) during the AE phase. Tasks that were completed infrequently by all residents include ensuring that the shoulder roll is available (11%) and ensuring access to head-of-bed (31%) during the preparation phase and applying shoulder roll (10%) and calling for help (23%) during the AE phase. The median time to recognition of AE from onset of hypoventilation was 33 seconds and that for delivery of oxygen and PPV was 60 and 97 seconds, respectively. Median confidence scores increased by PGY (PGY-1, 2; PGY-2, 3; PGY-3, 4; ANOVA F2,82 = 75, P< 0.0001). Conclusions Significant differences exist in the reported confidence and observed performance among PGY levels during simulated PS. Resident performance on this checklist demonstrates educational needs in PS training. A curriculum in PS for pediatric residents should focus on reviewing preparation steps, equipment, and potential interventions should an AE occur.

Development, implementation, and initial participant feedback of a pediatric sedation provider course.

Background: No standardized educational curriculum exists for pediatric sedation practitioners. We sought to describe the curriculum and implementation of a pediatric sedation provider course and assess learner satisfaction with the course curriculum. Description: The course content was determined by formulating a needs assessment using published sedation guidelines, reports of sedation related adverse events, and a survey of sedation practitioners. Students provided feedback regarding satisfaction with the course immediately following the course and 6 months later. Evaluation: The course consisted of 5 didactic lectures, 1 small-group session, 6 simulation scenarios, a course syllabus, and a written examination. The course was conducted over 1 day at 3 different locations. Sixty-nine students completed the course and were uniformly satisfied with the course curriculum. Conclusions: A standardized pediatric sedation provider course was developed for sedation practitioners and consisted of a series of lectures and simulation scenarios. Overall satisfaction with the course was positive.

Development of an Instrument for a Primary Airway Provider's Performance With an ICU Multidisciplinary Team in Pediatric Respiratory Failure Using Simulation

OBJECTIVE: To develop a scoring system that can assess the multidisciplinary management of respiratory failure in a pediatric ICU. METHODS: In a single tertiary pediatric ICU we conducted a simulation-based evaluation in a patient care area auxiliary to the ICU. The subjects were pediatric and emergency medicine residents, nurses, and respiratory therapists who work in the pediatric ICU. A multidisciplinary focus group with experienced providers in pediatric ICU airway management and patient safety specialists was formed. A task-based scoring instrument was developed to evaluate a primary airway providers performance through Healthcare Failure Mode and Effect Analysis. Reliability and validity of the instrument were evaluated using multidisciplinary simulation-based airway management training sessions. Each session was evaluated by 3 independent expert raters. A global assessment of the team performance and the previous experience in training were used to evaluate the validity of the instrument. RESULTS: The Just-in-Time Pediatric Airway Provider Performance Scale (JIT-PAPPS) version 3, with 34 task-based items (14 technical, 20 behavioral), was developed. Eighty-five teams led by resident airway providers were evaluated by 3 raters. The intraclass correlation coefficient for raters was 0.64. The JIT-PAPPS score correlated well with the global rating scale (r = 0.71, P < .001). Mean total scores across the teams were positively associated with resident previous training participation (β coefficient 7.1 ± 0.9, P < .001), suggesting good validity of the scale. CONCLUSIONS: A task-based scoring instrument for a primary airway providers performance with a multidisciplinary pediatric ICU team on simulated pediatric respiratory failure was developed. Reliability and validity evaluation supports the developed scale.

Kinetic therapy improves oxygenation in critically ill pediatric patients.

Objective: To compare changes in oxygenation after manual turning and percussion (standard therapy) and after automated rotation and percussion (kinetic therapy). Design: Randomized crossover trial. Setting: General and cardiac pediatric intensive care units. Patients: Intubated and mechanically ventilated pediatric patients who had an arterial catheter and no contraindications to using a PediDyne bed. Interventions: Patients were placed on a PediDyne bed (Kinetic Concepts) and received 18 hrs blocks of standard and kinetic therapy in an order determined by randomization. Measurements and Main Results: Arterial blood gases were measured every 2 hrs during each phase of therapy. Oxygenation index and arterial-alveolar oxygen tension difference [P(a-a)o2] were calculated. Indexes calculated at baseline and after each 18-hr phase of therapy were analyzed. Fifty patients were enrolled. Data from 15 patients were either not collected or not used due to reasons that included violation of protocol and inability to tolerate the therapies in the study. Indexes of oxygenation were not normally distributed and were compared using Wilcoxon signed rank testing. Both therapies led to improvements in oxygenation, but only those from kinetic therapy achieved statistical significance. In patients receiving kinetic therapy first, median oxygenation index decreased from 7.4 to 6.19 (p = .015). The median P(a-a)o2 decreased from 165.2 to 126.4 (p = .023). There were continued improvements in oxygenation after the subsequent period of standard therapy, with the median oxygenation index decreasing to 5.52 and median P(a-a)o2 decreasing to 116.0, but these changes were not significant (p = .365 and .121, respectively). When standard therapy was first, the median oxygenation index decreased from 8.83 to 8.71 and the median P(a-a)o2 decreased from 195.4 to 186.6. Neither change was significant. Median oxygenation index after the subsequent period of kinetic therapy was significantly lower (7.91, p = .044) and median P(a-a)o2 trended lower (143.4, p = .077). Conclusions: Kinetic therapy is more efficient than standard therapy at improving oxygenation and produces improvements in oxygenation that are more persistent.

Pediatric anesthesiology fellow education: is a simulation-based boot camp feasible and valuable?

Pediatric anesthesiologists must manage crises in neonates and children with timely responses and limited margin for error. Teaching the range of relevant skills during a 12‐month fellowship is challenging. An experiential simulation‐based curriculum can augment acquisition of knowledge and skills.

Focused Training for the Handover of Critical Patient Information During Simulated Pediatric Emergencies

OBJECTIVES Miscommunication has been implicated as a leading cause of medical errors, and standardized handover programs have been associated with improved patient outcomes. However, the role of structured handovers in pediatric emergencies remains unclear. We sought to determine if training with an airway, breathing, circulation, situation, background, assessment, recommendation handover tool could improve the transmission of essential patient information during multidisciplinary simulations of critically ill children. METHODS We conducted a prospective, randomized, intervention study with first-year pediatric residents at a quaternary academic childrens hospital. Baseline and second handovers were recorded for residents in the intervention group (n = 12) and residents in the control group (n = 8) during multidisciplinary simulations throughout the academic year. The intervention group received handover education after baseline handover observation and a cognitive aid before second handover observation. Audio-recorded handovers were scored by using a Delphi-developed assessment tool by a blinded rater. RESULTS There was no difference in baseline handover scores between groups (P = .69), but second handover scores were significantly higher in the intervention group (median 12.5 [interquartile range 12-13] versus median 7.5 [interquartile range 6-8] in the control group; P < .01). Trained residents were more likely to include a reason for the call (P < .01), focused history (P = .02), and summative assessment (P = .03). Neither timing of the second observation in the academic year nor duration between first and second observation were associated with the second handover scores (both P > .5). CONCLUSIONS Structured handover training and provision of a cognitive aid may improve the inclusion of essential patient information in the handover of simulated critically ill children.