Susanne Kost

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.

Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium

Background:  Pentobarbital and propofol are commonly used to sedate children undergoing magnetic resonance imaging (MRI). The Pediatric Sedation Research Consortium (PSRC) was created in 2003 to improve pediatric sedation process and outcomes.

Appropriateness of ambulance transportation to a suburban pediatric emergency department

OBJECTIVE To assess the appropriateness of ambulance use in patients presenting to a pediatric emergency department (ED), with regard to both medical necessity and insurance status. METHODS The authors conducted a one-year retrospective chart analysis of all patients (age range 2 weeks to 19 years) who were transported via ambulance in 1994 to a suburban childrens hospital ED. ED records of all patients who arrived by ambulance were abstracted for demographic data, type of insurance, chief complaint, medical interventions, discharge diagnosis, and disposition. Ambulance transportation was deemed unnecessary unless the medical record revealed any of the following criteria: 1) requiring cardiopulmonary resuscitation, 2) respiratory distress, 3) altered mental status or seizure, 4) immobilization, 5) inability to walk, 6) admission to intensive care, 7) ambulance recommended by medical personnel, 8) motor vehicle collision, or 9) parents not on scene. RESULTS 43% of the ambulance patients were insured by Medicaid, compared with 29% of the overall ED population. Thus, Medicaid patients were significantly more likely to use ambulance transportation than were patients with commercial insurance (p<0.001). 28% of patients who arrived by ambulance were judged to have used the ambulance transportation unnecessarily. Of the unnecessary transports, 60% were insured by Medicaid. Thus, Medicaid patients were significantly more likely to have used ambulance transportation unnecessarily (p<0.001). The most common reason for appropriate ambulance use was seizure activity; the most common reason for inappropriate use was fever. CONCLUSION Inappropriate use of ambulance transportation is common in this pediatric population, with Medicaid patients accounting for a significant majority of the misuse.

Great Expectations—Defining Quality in Pediatric Sedation: Outcomes of a Multidisciplinary Consensus Conference

Purpose:Recognizing the inconsistencies in sedation practices, the Society for Pediatric Sedation convened this meeting to begin the process of defining quality as it relates to the field of pediatric sedation. Scope:Millions of procedures are performed each year on children. Caring for children, even for routine procedures, can be challenging. Children may not have the ability to follow commands, tolerate painful stimuli, or even lie still for a diagnostic study. Therefore, pharmacologic sedation with medications designed to blunt the awareness of the patient and provide relief of pain and anxiety is necessary. Methods:A multidisciplinary group of sedation providers and quality methodology experts met in November 2011. Through 2 days of didactics, small workgroups, and consensus discussions, the attendees met the objectives of exploring quality in pediatric sedation around the Institute of Medicines (IOM, 2001) six aims of quality: Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Results:The conference findings outlined in this document address the Agency for Healthcare Research and Qualitys (AHRQ) mission of improving quality healthcare for all Americans, especially for underrepresented groups such as children. The conference outlines a key next step in defining and achieving quality in pediatric procedural sedation.

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 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.

Task and Procedural Skills Training

A suite of task trainers has been developed, specifically for pediatric use, for most of the procedures required to care for pediatric patients. They vary in their fidelity, usability, and durability. Availability of these task trainers is only the beginning of the procedural skills training puzzle. It is important to embed task trainers in well-developed curricula that include attention to evidence-based methodology and dissemination. The development of procedural competence has a rich literature base, which will also be reviewed in the chapter.