Stephanie N. Sudikoff

Theoretical foundations of learning through simulation.

Health care simulation is a powerful educational tool to help facilitate learning for clinicians and change their practice to improve patient outcomes and safety. To promote effective life-long learning through simulation, the educator needs to consider individuals, their experiences, and their environments. Effective education of adults through simulation requires a sound understanding of both adult learning theory and experiential learning. This review article provides a framework for developing and facilitating simulation courses, founded upon empiric and theoretic research in adult and experiential learning. Specifically, this article provides a theoretic foundation for using simulation to change practice to improve patient outcomes and safety.

Three scenarios to teach difficult discussions in pediatric emergency medicine: sudden infant death, child abuse with domestic violence, and medication error.

Within an emergency medicine (EM) environment, the pace of clinical care delivery rarely allows time to stop and observe extended interactions between trainees and patients, or to provide feedback on communication skills. Once residency and fellowship conclude, however, these same trainees will be required to manage complicated medical and social interactions independently. In particular, unique challenges in the realm of patient-doctor interaction arise in the field of pediatric emergency medicine (PEM), with most clinical encounters involving both a child and their caregiver. Whether delivering bad news to a family or screening and managing cases of suspected child abuse, child neglect or domestic violence, many physicians report having no formal training in communicating effectively and compassionately under difficult conditions.1–4 It is imperative to consider and prepare future physicians for the emotional relationship between the (pediatric) patient and the family when caring for the family unit, especially in emergent situations and times of crisis. The occurrence of medical error presents another tremendously challenging situation for physicians and requires sophisticated communications skills. Despite clinicians’ best preventive and conscientious efforts, various elements can lead to a medical error, and the physicians involved will need to disclose and discuss the event with the family. Once again, few physicians have had formal training in managing these situations.5 To improve training in PEM physician communications during difficult discussions, we created a hybrid medical simulation program, a combination of standardized patients and high-fidelity medical simulation. The primary objective was to educate EM residents and PEM fellows on the communication skills necessary to engage in difficult discussions when caring for children in an emergency department setting. Authors will present three scenarios developed for an educational activity designed to focus on difficult discussion communication skills in PEM.

Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions.

AIM The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest. METHODS We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate. RESULTS We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001). CONCLUSION The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

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.

An approach to unit-based team training with simulation in a neonatal intensive care unit

Introduction: Teamwork training with simulation has been utilized increasingly to improve communication among healthcare providers. Hospitals have developed programs to train employees in fundamentals of effective teamwork. It is beneficial to train all staff quickly to implement a culture change. Challenges with scheduling a multidisciplinary group represent a significant barrier to successful implementation. We describe various obstacles and solutions to facilitate training staff of the Yale Neonatal Intensive Care Unit. Methods: A multidisciplinary approach was used to schedule and train employees between October and November 2010. Neonatal attendings, fellows, nursing leadership and staff, nurse practitioners, physician assistants, respiratory therapists, patient care associates and business administrators participated. The curriculum was adapted from TeamSTEPPS™, designed by the Agency for Healthcare Research and Quality. Participants attended didactic lectures describing key concepts related to teamwork and participated in simulation. The Teamwork Attitudes Questionnaire (TAQ) was administered prior to training and a course feedback survey was obtained. Results: 176 employees from various disciplines received teamwork training in 25 multidisciplinary sessions held over 6 weeks. 164 TAQs were analyzed. Physicians perceived teamwork behaviors to be a 4.49/5 vs. 4.44/5 (practitioners), 4.40/5 (nurses), and 4.25/5 (other disciplines). Conclusions: Logistical issues included (1) high patient census preventing sessions from being conducted in situ and (2) scheduling conflicts preventing staff from participating. Participants ranked their teamwork highly prior to the session. They also ranked the course highly in the feedback survey. This approach could be used to conduct team training in a large unit.

Workload of Team Leaders and Team Members During a Simulated Sepsis Scenario

Objectives: Crisis resource management principles dictate appropriate distribution of mental and/or physical workload so as not to overwhelm any one team member. Workload during pediatric emergencies is not well studied. The National Aeronautics and Space Administration-Task Load Index is a multidimensional tool designed to assess workload validated in multiple settings. Low workload is defined as less than 40, moderate 40–60, and greater than 60 signify high workloads. Our hypothesis is that workload among both team leaders and team members is moderate to high during a simulated pediatric sepsis scenario and that team leaders would have a higher workload than team members. Design: Multicenter observational study. Setting: Nine pediatric simulation centers (five United States, three Canada, and one United Kingdom). Patients: Team leaders and team members during a 12-minute pediatric sepsis scenario. Interventions: National Aeronautics and Space Administration-Task Load Index. Measurements and Main Results: One hundred twenty-seven teams were recruited from nine sites. One hundred twenty-seven team leaders and 253 team members completed the National Aeronautics and Space Administration-Task Load Index. Team leader had significantly higher overall workload than team member (51 ± 11 vs 44 ± 13; p < 0.01). Team leader had higher workloads in all subcategories except in performance where the values were equal and in physical demand where team members were higher than team leaders (29 ± 22 vs 18 ± 16; p < 0.01). The highest category for each group was mental 73 ± 13 for team leader and 60 ± 20 for team member. For team leader, two categories, mental (73 ± 17) and effort (66 ± 16), were high workload, most domains for team member were moderate workload levels. Conclusions: Team leader and team member are under moderate workloads during a pediatric sepsis scenario with team leader under high workloads (> 60) in the mental demand and effort subscales. Team leader average significantly higher workloads. Consideration of decreasing team leader responsibilities may improve team workload distribution.

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy.

Background: GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). Purposes: This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. Methods: Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. Results: Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. Conclusions: A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

Simulation Curriculum Development, Competency-Based Education, and Continuing Professional Development

Simulation-based education offers the potential to support healthcare providers to develop and maintain the essential competencies relevant to clinical practice—in a manner that can help them improve patient care and outcomes. Competency frameworks and models for competency-based education may help support this transformational change in education and assessment. Simulation should be appropriately coupled with other instructional methods to deliver the appropriate curricula for learners. The analysis, design, development, implementation, and evaluation (ADDIE) model offers a process to develop, implement, and evaluate curricular development. Each of the key phases will be described and the key considerations of each phase will be discussed. Future directions including high-stakes examinations and the development of standardized national curricula are also discussed.