Hospital to Home: A Quality Improvement Initiative to Implement High-fidelity Simulation Training for Caregivers of Children Requiring Long-term Mechanical Ventilation.

BACKGROUND: Preparing families of children requiring long-term mechanical ventilation (LTMV) to manage medical emergencies at home is challenging. Opportunities for family caregivers to rehearse crisis management in a controlled setting before discharge are limited. OBJECTIVE: We aimed to create a multimodal discharge preparedness curriculum, incorporating high-fidelity simulation training, to prepare family caregivers of children with complex medical conditions requiring long-term mechanical ventilation. We sought to determine which curricular elements were most helpful and whether this curriculum impacted the rate of readmissions within 7 days of hospital discharge. METHODS: The curriculum included instructional videos, printed handouts, cardiopulmonary resuscitation training, and two mandatory high fidelity simulation scenarios depicting tracheostomy- and ventilator-related emergencies. Teams of one to three family caregivers per patient managed each scenario. A video-based debriefing focused on identifying and closing performance gaps. Participants rated their perceptions regarding each curricular element and its relative impact on their preparedness for discharge. RESULTS: 87 family caregivers completed the curriculum. Simulation-enhanced curriculum was well-received by participants. Participants reported that post-simulation debriefing was the most beneficial component. We observed a trend toward reduced readmissions within 7 days of discharge since implementation of our revised curriculum. CONCLUSION: Simulation training can be incorporated into discharge training for families of children requiring LTMV. Rehearsal of emergency management in a simulated clinical setting increases caregiver confidence to assume care for their ventilator-dependent child.

A twenty-year study of long-term and temporary dominance relations among stumptailed macaques (Macaca arctoides).

Consistent individual differences in long-term dominance are a basic underlying assumption of hypotheses linking dominance and reproductive success. Long-term and temporary dominance of a colony group of stumptailed macaques was studied for 20 years. There were two variously constituted groups for the first 4 years and a single group for the last 16. Stumptails displayed the matrilineal dominance organization found for several other cercopithecine species. A method was devised to standardize ranks so they could be compared over the years across groups of varying size and composition. No animal maintained the same dominance rank over the entire period of the research or over the last 16 years, but there was considerable consistency over long periods. Although occupants of the male and female alpha positions changed several times, one female was dominant for 18 of the 20 years. She was dominant in 1968, at the start of the study, and at its end in 1988 at which time her 18-year-old son was the dominant male. Variation in dominance ranks was greatest among members of mid-ranking matrilines and least for the lowest ranking. The same female or her son were the lowest ranking animals of their groups in all samples taken over the entire 20 years.