A randomized, controlled trial of in situ pediatric advanced life support recertification ("pediatric advanced life support reconstructed") compared with standard pediatric advanced life support recertification for ICU frontline providers*.

OBJECTIVE: Recent evidence shows poor retention of Pediatric Advanced Life Support provider skills. Frequent refresher training and in situ simulation are promising interventions. We developed a "Pediatric Advanced Life Support-reconstructed" recertification course by deconstructing the training into six 30-minute in situ simulation scenario sessions delivered over 6 months. We hypothesized that in situ Pediatric Advanced Life Support-reconstructed implementation is feasible and as effective as standard Pediatric Advanced Life Support recertification. DESIGN: A prospective randomized, single-blinded trial. SETTING: Single-center, large, tertiary PICU in a university-affiliated children's hospital. SUBJECTS: Nurses and respiratory therapists in PICU. INTERVENTIONS: Simulation-based modular Pediatric Advanced Life Support recertification training. MEASUREMENTS AND MAIN RESULTS: Simulation-based pre- and postassessment sessions were conducted to evaluate participants' performance. Video-recorded sessions were rated by trained raters blinded to allocation. The primary outcome was skill performance measured by a validated Clinical Performance Tool, and secondary outcome was behavioral performance measured by a Behavioral Assessment Tool. A mixed-effect model was used to account for baseline differences. Forty participants were prospectively randomized to Pediatric Advanced Life Support reconstructed versus standard Pediatric Advanced Life Support with no significant difference in demographics. Clinical Performance Tool score was similar at baseline in both groups and improved after Pediatric Advanced Life Support reconstructed (pre, 16.3 ± 4.1 vs post, 22.4 ± 3.9; p < 0.001), but not after standard Pediatric Advanced Life Support (pre, 14.3 ± 4.7 vs post, 14.9 ± 4.4; p =0.59). Improvement of Clinical Performance Tool was significantly higher in Pediatric Advanced Life Support reconstructed compared with standard Pediatric Advanced Life Support (p = 0.006). Behavioral Assessment Tool improved in both groups: Pediatric Advanced Life Support reconstructed (pre, 33.3 ± 4.5 vs post, 35.9 ± 5.0; p = 0.008) and standard Pediatric Advanced Life Support (pre, 30.5 ± 4.7 vs post, 33.6 ± 4.9; p = 0.02), with no significant difference of improvement between both groups (p = 0.49). CONCLUSIONS: For PICU-based nurses and respiratory therapists, simulation-based "Pediatric Advanced Life Support-reconstructed" in situ training is feasible and more effective than standard Pediatric Advanced Life Support recertification training for skill performance. Both Pediatric Advanced Life Support recertification training courses improved behavioral performance.

Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine.

Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation-based training as needed (Maintain). Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.

Pulmonary glial heterotopia in a monoamniotic twin.

Brain heterotopia in the lungs is rare, but when it occurs in an otherwise healthy newborn, it presents a difficult diagnostic problem and uncertain pathophysiology. We report on a 2-week-old premature infant who presented with respiratory distress and widespread cystic lung changes identified by chest imaging studies. Autopsy demonstrated that the cyst walls were composed of well-differentiated neuroglial tissue, which was confirmed by immunohistochemistry. The cysts were partially lined by bronchial epithelium and contained keratinous debris. For the first time, we demonstrate that the debris stain for human chorionic gonadotropin, compatible with aspirated amnion. There were no other congenital abnormalities. Her monoamniotic twin was anencephalic and died at birth. Although the etiology of glial heterotopia in the lungs is unknown, the majority of cases are associated with anencephalic newborns. Some authors postulated that this heterotopia may therefore be a consequence of fetal aspiration of brain tissue. Other possibilities include glial predominant teratomas, hamartomatous malformations, and abnormal neural crest migration. Our review of the 21 cases reported over the past century suggests that in utero aspiration of glial cells, or abnormal neural crest migration, are the most likely explanations for this rare and fatal disease.

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.

Using simulation to enhance the acquisition and retention of clinical skills in neonatology.

Neonatal care occurs in extremely complex and dynamic environments and requires providers to operate under intense time pressure in coordination with multiple disciplines. Teaching the clinical skills requisite to effective practice requires the meticulous application of curricular design principles. Simulation can be used as an effective instructional strategy in achieving learner acquisition and retention of the cognitive, technical, and behavioral skills essential to optimal delivery of care in neonatology.

EXPRESS--Examining Pediatric Resuscitation Education Using Simulation and Scripting. The birth of an international pediatric simulation research collaborative--from concept to reality.

Over the past decade, medical simulation has evolved into an essential component of pediatric resuscitation education and team training. Evidence to support its value as an adjunct to traditional methods of education is expanding; however, large multicenter studies are very rare. Simulation-based researchers currently face many challenges related to small sample sizes, poor generalizability, and paucity of clinically proven and relevant outcome measures. The Examining Pediatric Resuscitation Education Using Simulation and Scripting (EXPRESS) pediatric simulation research collaborative was formed in an attempt to directly address and overcome these challenges. The primary mission of the EXPRESS collaborative is to improve the delivery of medical care to critically ill children by answering important research questions pertaining to pediatric resuscitation and education and is focused on using simulation either as a key intervention of interest or as the outcome measurement tool. Going forward, the collaborative aims to expand its membership internationally and collectively identify pediatric resuscitation and simulation-based research priorities and use these to guide future projects. Ultimately, we hope that with innovative and high-quality research, the EXPRESS pediatric simulation research collaborative will help to build momentum for simulation-based research on an international level.

Instructional design dogma: creating planned learning experiences in simulation.

Human lives depend on the performance of our trainees; thus, the educational methodology used to transform our learners into experts are of paramount importance. Effective use of simulation requires educators explore and apply educational theory as they discover who the learner is, how the learner learns, what the learning needs are, and which planned learning experiences are best suited to meet the learner's specialized needs. The purpose of this article is to portray simulation as an educational strategy in the context of a curriculum, to explore emerging theories from educational psychology, and to provide concrete examples of their application in simulation-based education.

Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience.

BACKGROUND: There are no reports in the literature that compare instructor-modeled learning to self-directed learning when simulation is used. Therefore, no evidence exists to know which approach is superior. This study aims to test the hypothesis that instructor-modeled learning is more effective compared with self-directed learning during a simulated clinical experience. METHODS: This is a descriptive pilot study to compare instructor-modeled learning with self-directed learning during a clinical simulated experience. Four evaluation tools were used at three time points to evaluate knowledge, self-efficacy (self confidence), and behaviors. RESULTS: Sixteen students participated. There were no statistically significant differences between the groups on the Knowledge Assessment Test. There were significant differences between the groups in the Self-Efficacy Tool (SET) at three times (time 1: P = 0.006, time 2: P = 0.008, time 3: P = 0.012). The only significance between the groups on the Technical Evaluation Tool was time to start Albuterol. The Behavioral Assessment Tool (BAT) showed significant differences between the groups in 8 out of 10 components of the tool. A strong correlation was observed between the overall score of the BAT and the SET Score. CONCLUSION: Although the small sample size prohibits definitive conclusions, the data suggest that instructor-modeled learning may be more effective than self-directed learning for some aspects of learning during a clinical simulated experience.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills.

BACKGROUND: Healthcare professionals are expected to make rapid, correct decisions in critical situations despite what may be a lack of real practical experience in a particular crisis situation. Successful resolution of a medical crisis depends upon demonstration not only of appropriate technical skills but also of key behavioral skills (eg, leadership, communication, and teamwork). We have developed a hands-on, high fidelity, simulation-based training program (ECMO Sim) to provide healthcare professionals with the opportunity to learn and practice the technical and behavioral skills necessary to manage ECMO emergencies. METHODS: Nine ECMO nurse specialists participated in two sequential randomly assigned simulated ECMO emergencies. The simulated emergencies were captured on videotape and reviewed with the subjects during facilitated debriefings that occurred immediately following each scenario. All videotapes were scored for key technical and behavioral skills by reviewers blinded to the sequence of the scenarios. The ratings of the subjects' technical and behavioral skills in each scenario were compared. RESULTS: Subjects performed key technical skills correctly more often in the second simulated ECMO emergency. In addition, their response times for three out of five specific technical tasks improved from the first to the second simulated emergency by an average of 27 seconds. Subjects' behavioral skills were rated more highly by masked reviewers in the second simulated ECMO emergency. The improvement in comprehensive behavioral scores from the first to the second scenario reached statistical significance in eight of nine subjects. CONCLUSION: After exposure to high-fidelity simulated ECMO emergencies, subjects demonstrated significant improvements in their technical and behavioral skills. ECMO Sim creates a learning environment that readily supports the acquisition of the technical and behavioral skills that are important in solving clinically significant, potentially life-threatening problems that can occur when patients are on ECMO.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. METHODS: A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. RESULTS: Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. CONCLUSION: Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Development of a quality assessment scale for retrospective clinical studies in pediatric surgery.

BACKGROUND/PURPOSE: More than 97% of the clinical research in pediatric surgery consists of retrospective data. Although these studies have significant limitations, they fundamentally shape clinical practice within the field. In this report, the authors describe the development and potential applications of a standardized quality assessment scale designed for retrospective studies in pediatric surgery. METHODS: The authors developed a comprehensive quality assessment instrument incorporating 30 items within 3 subscales. These subscales were designed to assess 3 integral components of study design: clinical relevance, reporting methodology, and the strength of conclusions. Global quality ratings (poor, fair, or good) were derived by combining scores from each subscale. To examine inter-rater reliability, 10 retrospective studies from the pediatric surgery literature were assessed with the instrument by 6 independent reviewers. RESULTS: Inter-rater reliability was excellent as assessed by the level of agreement for all items within the instrument (84.6% concordance, n = 1,573 total item-choices) and for individual subscales (range, 73.3% to 85.8%, n = 60 to 1,258). The extent of agreement among reviewers was 82% for classifying reports into qualitative categories by global quality scores (n = 60). The ranking of papers by individual reviewers was highly predictive of overall ranking by mean quality scores (n = 60 rank pairs, r = 0.83; P <.01). CONCLUSIONS: The authors have developed a standardized and reliable quality assessment scale for the analysis of retrospective data in pediatric surgery. Potential applications include: (1) providing the practicing surgeon with a knowledge base to critically evaluate published retrospective data; (2) providing a standardized methodology for the systematic review of existing retrospective data; and (3) developing standardized reporting guidelines for use in peer-reviewed journals.

High-fidelity simulation-based training in neonatal nursing.

Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.