The Integration of Quality Improvement and Health Care Simulation: A Scoping Review.

BACKGROUND AND OBJECTIVES: Quality improvement (QI) and simulation employ complementary approaches to improve the care provided to patients. There is a significant opportunity to leverage these disciplines, yet little is known about how they are utilized in concert. The purpose of this study is to explore how QI and simulation have been used together in health care. METHODS: This scoping review includes studies published between 2015 and 2021 in 4 databases: CINAHL, Embase, PubMed, and Scopus. RESULTS: The search yielded 921 unique articles.18 articles met the inclusion criteria and specifically described QI and simulation collaborative projects. Of the 18 articles, 28% focused on improvements in patient care, 17% on educational interventions, 17% on the identification of latent safety threats (LSTs) that could have an impact on clinical care, 11% on the creation of new processes, 11% on checklist creation, and 6% on both LST identification and educational intervention. The review revealed that 61% of the included studies demonstrated a concurrent integration of simulation and QI activities, while 33% used a sequential approach. CONCLUSIONS: There is a paucity of studies detailing the robust and synergistic use of QI and simulation. The findings of this review suggest a positive impact on patient safety when QI and simulation are used in tandem. The systematic integration of these disciplines and the use of established reporting guidelines can promote patient safety in practice and in the literature.

Debriefer cognitive load during Traditional Reflective Debriefing vs. Rapid Cycle Deliberate Practice interdisciplinary team training.

BACKGROUND: Cognitive load impacts performance of debriefers and learners during simulations, but limited data exists examining debriefer cognitive load. The aim of this study is to compare the cognitive load of the debriefers during simulation-based team training (SbTT) with Rapid Cycle Deliberate Practice (RCDP) debriefing and Traditional Reflective Debriefing (TRD). We hypothesize that cognitive load will be reduced during RCDP compared to TRD. METHODS: This study was part of a large-scale, interdisciplinary team training program at Children's Healthcare of Atlanta Egleston Pediatric Emergency Department, with 164 learners (physicians, nurses, medical technicians, paramedics, and respiratory therapists (RTs)). Eight debriefers (main facilitators and discipline-specific coaches) led 28 workshops, which were quasi-randomized to either RCDP or TRD. Each session began with a baseline medical resuscitation scenario and cognitive load measurement using the NASA Task Load Index (TLX), and the NASA TLX was repeated immediately following either TRD or RCDP debriefing. Raw scores of the NASA TLX before and after intervention were compared. ANOVA tests were used to compare differences in NASA TLX scores before and after intervention between the RCDP and TRD groups. RESULTS: For all debriefers, mean NASA TLX scores for physical demands and frustration significantly decreased (- 0.8, p = 0.004 and - 1.3, p = 0.002) in TRD and mean perceived performance success significantly increased (+ 2.4, p < 0.001). For RCDP, perceived performance success increased post-debriefing (+ 3.6, p < 0.001), time demands decreased (- 1.0, p = 0.04), and frustration decreased (- 2.0, p < 0.001). Comparing TRD directly to RCDP, perceived performance success was greater in RCDP than TRD (3.6 vs. 2.4, p = 0.04). Main facilitators had lower effort and mental demand in RCDP and greater perceived success (p < 0.001). CONCLUSION: RCDP had greater perceived success than TRD for debriefers. Main facilitators also report reduced effort and baseline mental demand in RCDP. For less experienced debriefers, newer simulation programs, or large team training sessions such as our study, RCDP may be a less mentally demanding debriefing methodology for facilitators.

A comparison of rapid cycle deliberate practice and traditional reflective debriefing on interprofessional team performance.

BACKGROUND: In simulation-based education, debriefing is necessary to promote knowledge acquisition and skill application. Rapid Cycle Deliberate Practice (RCDP) and Traditional Reflective Debriefing (TRD) are based in learning theories of deliberate practice and reflective learning, respectively. In this study, we compared the effectiveness of TRD versus RCDP on acquisition of conceptual knowledge and teamwork skills among interdisciplinary learners in the pediatric emergency department. METHODS: One hundred sixty-four learners including emergency department attending physicians, fellows, nurses, medical technicians, paramedics, and respiratory therapists, participated in 28 in-situ simulation workshops over 2 months. Groups were quasi-randomized to receive RCDP or TRD debriefing. Learners completed a multiple-choice test to assess teamwork knowledge. The TEAM Assessment Tool assessed team performance before and after debriefing. Primary outcomes were teamwork knowledge and team performance. RESULTS: Average pre-intervention baseline knowledge assessment scores were high in both groups (TRD mean 90.5 (SD 12.7), RCDP mean 88.7 (SD 15.5). Post-test scores showed small improvements in both groups (TRD mean 93.2 (SD 12.2), RCDP mean 89.9 (SD 13.8), as indicated by effect sizes (ES = 0.21 and 0.09, for TRD and RCDP, respectively). Assessment of team performance demonstrated a significant improvement in mean scores from pre-assessment to post-assessment for all TEAM Assessment skills in both TRD and RCDP arms, based on p-values (all p < 0.01) and effect sizes (all ES > 0.8). While pre-post improvements in TEAM scores were generally higher in the RCDP group based on effect sizes, analysis did not indicate either debriefing approach as meaningfully improved over the other. CONCLUSIONS: Our study did not demonstrate that either TRD versus RCDP was meaningfully better in teamwork knowledge acquisition or improving skill application and performance. As such, we propose Reflective Deliberate Practice as a framework for future study to allow learners to reflect on learning and practice in action.

Optimizing Antibiotic Treatment of Skin Infections in Pediatric Emergency and Urgent Care Centers.

OBJECTIVES: The objective was to optimize antibiotic choice and duration for uncomplicated skin/soft tissue infections (SSTIs) discharged from pediatric emergency departments (EDs) and urgent cares (UCs). METHODS: Pediatric patients aged 0 to 18 years discharged from 3 pediatric EDs and 8 UCs with a diagnosis of uncomplicated SSTIs were included. Optimal treatment was defined as 5 days of cephalexin for nonpurulent SSTIs and 7 days of clindamycin or trimethoprim/sulfamethoxazole for purulent SSTIs. Exclusion criteria included erysipelas, folliculitis, felon, impetigo, lymphangitis, paronychia, perianal abscess, phlegmon, preseptal or orbital cellulitis, and cephalosporin allergy. Baseline data were collected from January 2018 to June 2019. Quality improvement (QI) interventions began July 2019 with a revised SSTI guideline, discharge order set, and maintenance of certification (MOC) QI project. MOC participants received 3 education sessions, monthly group feedback, and individual scorecards. Balancing measures included return visits within 10 days requiring escalation of care. Data were monitored through March 2021. RESULTS: In total, 9306 SSTIs were included. The MOC QI project included 50 ED and UC physicians (27% of eligible physicians). For purulent SSTI, optimal antibiotic choice, plus duration, increased from a baseline median of 28% to 64%. For nonpurulent SSTI, optimal antibiotic choice, plus duration, increased from a median of 2% to 43%. MOC participants had greater improvement than non-MOC providers (P < .010). Return visits did not significantly change pre- to postintervention, remaining <2%. CONCLUSIONS: We improved optimal choice and reduced duration of antibiotic treatment of outpatient SSTIs. MOC participation was associated with greater improvement and was sustained after the intervention period.

Use of POCUS in the Diagnosis of Paradoxical Vocal Cord Movement.

ABSTRACT: Point-of-care ultrasound has been instrumental in allowing providers to make prompt diagnoses at the bedside but has been historically underutilized for the diagnosis of upper airway processes, including paradoxical vocal fold motion (PVFM), also known as vocal cord dysfunction. PVFM is characterized by adduction of the vocal cords during inspiration, resulting in stridor and shortness of breath. This case report describes a teenage girl who presented to the pediatric emergency department (ED) with difficulty breathing. Point-of-care ultrasound diagnosed PVFM, which was confirmed with bedside flexible laryngoscopy by otorhinolaryngology (ENT) in the ED.