A Brief, Just-in-Time Sedation Training in the Pediatric Emergency Department Improves Performance During Adverse Events Encountered in Simulated Procedural Sedations.

BACKGROUND: Procedural sedation (PS) is commonly performed in emergency departments (EDs) by nonanesthesiologists. Although adverse events (AEs) are rare, providers must possess the clinical skills to react in a timely manner. We previously described residents' experience and confidence in PS as part of a needs assessment. We found that their ability to perform important clinical tasks as a result of the usual training experience demonstrates educational needs. We developed an educational intervention to address the deficiencies uncovered during our needs assessment. OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' clinical performance and confidence when faced with an AE during a simulated PS. METHODS: This was a prospective observational cohort study of residents at a tertiary care children's hospital. All ED attending physicians and fellows were trained in uniform delivery of the educational intervention, which was delivered extemporaneously at the bedside ("Just-in-Time" [JIT]) to all residents performing PS on actual patients in the pediatric ED, over the course of 1 year. Subjects completed the following both before and after the educational intervention: a survey pertaining to confidence in PS, followed by a standardized, video-recorded simulated PS complicated by apnea and desaturation. Clinical performance was evaluated and assessed both in real time and by a video-rater blinded to participants' year of training. We summarized baseline resident characteristics, confidence questionnaire item rankings and success in both the preparation and AE tasks. We compared successful task completion and time to task completion before and after intervention. RESULTS: Forty residents completed both the PRE and POST phases of the study. There was significant improvement in the proportion of residents who completed both preparation and AE tasks after the JIT training. Specifically, there was a significant improvement in the proportion of residents who performed positive-pressure ventilation to treat an apneic event associated with desaturation during the PS (P = 0.007). Residents' confidence scores also significantly improved after the training. CONCLUSION: A brief JIT training in the pediatric ED improves resident clinical performance and confidence when faced with an AE during a simulated PS. Future direction includes correlating this improved performance with patient outcomes in PS.

The impact of simulation-based medical education on resident management of emergencies in pediatric anesthesiology.

BACKGROUND: Resident education in pediatric anesthesiology is challenging. Traditional curricula for anesthesiology residency programs have included a combination of didactic lectures and mentored clinical service, which can be variable. Limited pediatric medical knowledge, technical inexperience, and heightened resident anxiety further challenge patient care. We developed a pediatric anesthesia simulation-based curriculum to address crises related to hypoxemia and dysrhythmia management in the operating room as an adjunct to traditional didactic and clinical experiences. AIMS: The primary objective of this trial was to evaluate the impact of a simulation curriculum designed for anesthesiology residents on their performance during the management of crises in the pediatric operating room. A secondary objective was to compare the retention of learned knowledge by assessment at the eight-week time point during the rotation. METHODS: In this prospective, observational trial 30 residents were randomized to receive simulation-based education on four perioperative crises (Laryngospasm, Bronchospasm, Supraventricular Tachycardia (SVT), and Bradycardia) during the first week (Group A) or fifth week (Group B) of an eight-week rotation. Assessment sessions that included two scenarios (Laryngospasm, SVT) were performed in the first week, fifth week, and the eighth week of their rotation for all residents. The residents were assessed in real time and by video review using a 7-point checklist generated by a modified Delphi technique of senior pediatric anesthesiology faculty. RESULTS: Residents in Group A showed improvement between the first week and fifth week assessment as well as between first week and eighth week assessments without decrement between the fifth week and eighth week assessments for both the laryngospasm and SVT scenarios. Residents in Group B showed improvement between the first week and eighth week assessments for both scenarios and between the fifth week and eighth week assessment for the SVT scenario. CONCLUSION: This adjunctive simulation-based curriculum enhanced the learner's management of laryngospasm and SVT management and is a reasonable addition to didactic and clinical curricula for anesthesiology residents.

Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.

Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.

Pediatric anesthesiology fellow education: is a simulation-based boot camp feasible and valuable?

BACKGROUND: Pediatric anesthesiologists must manage crises in neonates and children with timely responses and limited margin for error. Teaching the range of relevant skills during a 12-month fellowship is challenging. An experiential simulation-based curriculum can augment acquisition of knowledge and skills. OBJECTIVES: To develop a simulation-based boot camp (BC) for novice pediatric anesthesiology fellows and assess learner perceptions of BC activities. We hypothesize that BC is feasible, not too basic, and well received by fellows. METHODS: Skills stations, team-based in situ simulations, and group discussions of complex cases were designed. Stations were evaluated by anonymous survey; fellows rated usefulness in improving knowledge, self-confidence, technical skill, and clinical performance using a Likert scale (1 strongly disagree to 5 strongly agree). They were also asked if stations were too basic or too short. Median and interquartile range (IQR) data were calculated and noted as median (IQR). RESULTS: Fellows reported the difficult airway station and simulated scenarios improved knowledge, self-confidence, technical skill, and clinical performance. They disagreed that stations were too basic or too short with exception of the difficult airway session, which was too short [4 (4-3)]. Fellows believed the central line station improved knowledge [4 (4-3)], technical skills [4 (4-4)], self-confidence [4 (4-3)], and clinical performance [4 (4-3)]; scores trended toward neutral likely because the station was perceived as too basic [3.5 (4-3)]. An interactive session on epinephrine and intraosseous lines was valued. Complicated case discussion was of educational value [4 (5-4)], the varied opinions of faculty were helpful [4 (5-4)], and the session was neither too basic [2 (2-2)] nor too short [2 (2-2)]. CONCLUSION: A simulation-based BC for pediatric anesthesiology fellows was feasible, perceived to improve confidence, knowledge, technical skills, and clinical performance, and was not too basic.

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.

Assessing pediatric residents' clinical performance in procedural sedation: a simulation-based needs assessment.

OBJECTIVES: Our primary objective in this study was to perform a needs assessment of clinical performance during simulated procedural sedation (PS) by pediatric residents. Our secondary objective was to describe reported experience and confidence with PS during pediatric residency. METHODS: In this prospective observational cohort study, pediatric residents completed a survey of 15 Likert-scaled items pertaining to confidence in PS, followed by performance of a standardized, video-recorded simulated PS complicated by an adverse event (AE): apnea and desaturation. Clinical performance was evaluated according to an expert consensus-derived checklist of critical tasks. The difference in reported confidence between postgraduate years (PGY) was assessed by one-way analysis of variance (ANOVA); clinical checklist items were quantified descriptively. RESULTS: A total of 35 PGY-1, 39 PGY-2, and 7 PGY-3 residents participated. The most frequently completed tasks by all residents are ensuring the cardiorespiratory monitor (73%) and connecting the oxygen tubing (70%) during the preparation phase and recognizing AE (97%) and administering oxygen (95%) during the AE phase. Tasks that were completed infrequently by all residents include ensuring that the shoulder roll is available (11%) and ensuring access to head-of-bed (31%) during the preparation phase and applying shoulder roll (10%) and calling for help (23%) during the AE phase. The median time to recognition of AE from onset of hypoventilation was 33 seconds and that for delivery of oxygen and PPV was 60 and 97 seconds, respectively. Median confidence scores increased by PGY (PGY-1, 2; PGY-2, 3; PGY-3, 4; ANOVA F2,82 = 75, P< 0.0001). CONCLUSIONS: Significant differences exist in the reported confidence and observed performance among PGY levels during simulated PS. Resident performance on this checklist demonstrates educational needs in PS training. A curriculum in PS for pediatric residents should focus on reviewing preparation steps, equipment, and potential interventions should an AE occur.

Development of an instrument for a primary airway provider's performance with an ICU multidisciplinary team in pediatric respiratory failure using simulation.

OBJECTIVE: To develop a scoring system that can assess the multidisciplinary management of respiratory failure in a pediatric ICU. METHODS: In a single tertiary pediatric ICU we conducted a simulation-based evaluation in a patient care area auxiliary to the ICU. The subjects were pediatric and emergency medicine residents, nurses, and respiratory therapists who work in the pediatric ICU. A multidisciplinary focus group with experienced providers in pediatric ICU airway management and patient safety specialists was formed. A task-based scoring instrument was developed to evaluate a primary airway provider's performance through Healthcare Failure Mode and Effect Analysis. Reliability and validity of the instrument were evaluated using multidisciplinary simulation-based airway management training sessions. Each session was evaluated by 3 independent expert raters. A global assessment of the team performance and the previous experience in training were used to evaluate the validity of the instrument. RESULTS: The Just-in-Time Pediatric Airway Provider Performance Scale (JIT-PAPPS) version 3, with 34 task-based items (14 technical, 20 behavioral), was developed. Eighty-five teams led by resident airway providers were evaluated by 3 raters. The intraclass correlation coefficient for raters was 0.64. The JIT-PAPPS score correlated well with the global rating scale (r = 0.71, P < .001). Mean total scores across the teams were positively associated with resident previous training participation (ß coefficient 7.1 ± 0.9, P < .001), suggesting good validity of the scale. CONCLUSIONS: A task-based scoring instrument for a primary airway provider's performance with a multidisciplinary pediatric ICU team on simulated pediatric respiratory failure was developed. Reliability and validity evaluation supports the developed scale.

Utilizing Competence-Based Simulation to Improve Orientation Outcomes.

BACKGROUND: New graduate respiratory therapists (RTs), regardless of the degree program, receive limited preparation in neonatal/pediatric diseases and management. Experienced RTs typically have adult knowledge but limited exposure to pediatrics. We developed a program that included competence-based simulation to improve orientation success. METHODS: A 9-week orientation program curriculum with simulation-based competence assessment was developed to ensure all new hires gained knowledge and skills to perform pediatric clinical tasks. Each new hire individually completed the same simulation scenarios during the first week and last week of orientation. Curriculum changes were made over time based on performance in simulations and on-the-job knowledge and skills during and after orientation. Paired and unpaired t tests were used with P < .05 as significant. RESULTS: From January 2017-February 2020, the program had 3 updates. Noninvasive ventilation and decompensating patient scenarios were completed for all periods. Ninety-two new staff were oriented in period 1 = 29 (new graduate RTs 20, experienced RTs 9); period 2 = 17 (new graduate RTs 10, experienced RTs 7); period 3 = 24 (new graduate RTs 21, experienced RTs 3), and period 4 = 22 (new graduate RTs = 22). Remediation during orientation occurred in 15% of the staff. Seventy-one percent successfully advanced to ICU orientation after completion of the program. All staff improved scores between pre- versus post-simulations in all periods: mean difference ± SD period 1: new graduate RTs 32.0 ± 17.0, P < .001; experienced RTs 28.0 ± 18.9, P < .001; period 2: new graduate RTs 23.0 ± 15.2, P < .001; experienced RTs 29.0 ± 12.1, P < .001; period 3: new graduate RTs 26.0 ± 15.8, P < .001; experienced RTs 27.0 ± 15.1, P = .007; and period 4: new graduate RTs 19.0 ± 14.5, P < .001, paired t test. The scores between new graduate RTs and experienced RTs during post-simulation were not significantly different for period 1 (P = .35) but were significantly different for periods 2-4 (P = .040, unpaired t test). CONCLUSIONS: The use of a competence-based orientation program showed educational advancements and helped determine successful orientation completion.

Be Prepared: A Pediatric Simulation Center's Early Pandemic Contributions.

INTRODUCTION: The COVID-19 pandemic forced healthcare institutions to rapidly adapt practices for patient care, staff safety, and resource management. We evaluated contributions of the simulation center in a freestanding children's hospital during the early stages of the pandemic. METHODS: We reviewed our simulation center's activity for education-based and system-focused simulation for 2 consecutive academic years (AY19: 2018-2019 and AY20: 2019-2020). We used statistical control charts and χ 2 analyses to assess the impact of the pandemic on simulation activity as well as outputs of system-focused simulation during the first wave of the pandemic (March-June 2020) using the system failure mode taxonomy and required level of resolution. RESULTS: A total of 1983 event counts were reported. Total counts were similar between years (994 in AY19 and 989 in AY20). System-focused simulation was more prevalent in AY20 compared with AY19 (8% vs. 2% of total simulation activity, P < 0.001), mainly driven by COVID-19-related simulation events. COVID-19-related simulation occurred across the institution, identified system failure modes in all categories except culture, and was more likely to identify macro-level issues than non-COVID-19-related simulation (64% vs. 44%, P = 0.027). CONCLUSIONS: Our simulation center pivoted to deliver substantial system-focused simulation across the hospital during the first wave of the COVID-19 pandemic. Our experience suggests that simulation centers are essential resources in achieving safe and effective hospital-wide improvement.

Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit.

OBJECTIVE: Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. DESIGN: Prospective, observational pilot study. SETTING: Single tertiary children's hospital pediatric intensive care unit. SUBJECTS: Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. INTERVENTIONS: A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. MEASUREMENTS AND MAIN RESULTS: For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd). CONCLUSIONS: It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

A practical guide to virtual debriefings: communities of inquiry perspective.

Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Virtual debriefings involve educators facilitating conversations through web-based videoconferencing platforms. Facilitating debriefings through a computer interface introduces a unique set of challenges. Educators require practical guidance to support meaningful virtual learning in the transition from in-person to virtual debriefings. The communities of inquiry conceptual framework offer a useful structure to organize practical guidance for conducting virtual debriefings. The communities of inquiry framework describe the three key elements-social presence, teaching presence, and cognitive presence-all of which contribute to the overall learning experience. In this paper, we (1) define the CoI framework and describe its three core elements, (2) highlight how virtual debriefings align with CoI, (3) anticipate barriers to effective virtual debriefings, and (4) share practical strategies to overcome these hurdles.

A multi-institutional high-fidelity simulation "boot camp" orientation and training program for first year pediatric critical care fellows.

OBJECTIVE: Simulation training has been used to integrate didactic knowledge, technical skills, and crisis resource management for effective orientation and patient safety. We hypothesize multi-institutional simulation-based training for first year pediatric critical care (PCC) fellows is feasible and effective. DESIGN: Descriptive, educational intervention study. SETTING: The simulation facility at the host institution. INTERVENTIONS: A multicentered simulation-based orientation training "boot camp" for first year PCC fellows was held at a large simulation center. Immediate posttraining evaluation and 6-month follow-up surveys were distributed to participants. MEASUREMENTS AND MAIN RESULTS: A novel simulation-based orientation training for first year PCC fellows was facilitated by volunteer faculty from seven institutions. The two and a half day course was organized to cover common PCC crises. High-fidelity simulation was integrated into each session (airway management, vascular access, resuscitation, sepsis, trauma/traumatic brain injury, delivering bad news). Twenty-two first year PCC fellows from nine fellowship programs attended, and 13 faculty facilitated, for a total of 15.5 hours (369 person-hours) of training. This consisted of 2.75 hours for whole group didactic sessions (17.7%), 1.08 hours for a small group interactive session (7.0%), 4.67 hours for task training (30.1%), and 7 hours for training (45.2%) with high-fidelity simulation and crisis resource management. A "train to success" approach with repetitive practice of critical assessment and interventional skills yielded higher scores in training effectiveness in the end-of-course evaluation. A follow-up survey revealed this training was highly effective in improving clinical performance and self-confidence. CONCLUSIONS: The first PCC orientation training integrated with simulation was effective and logistically feasible. The train to success concept with repetitive practice was highly valued by participants. Continuation and expansion of this novel multi-institutional training is planned.

Disclosure of Adverse Events: A Guide for Clinicians.

INTRODUCTION: Children's Hospitals' Solutions for Patient Safety (SPS) acknowledged a recommendation from the American Academy of Pediatrics to develop education programs on the communication of adverse events with patients and families. SPS set out to create a guide that would outline a standardized disclosure process and provide a training curriculum and tools so that providers would feel better prepared to have effective disclosure conversations. METHODS: SPS disclosure work began with the development of a project team made up of 9 network hospitals. The team utilized key driver diagrams and process maps to show the relationship between the project aims, key drivers, and specific interventions. The team developed a training curriculum, guide, and tools for each area of improvement. To ensure these were effective, they were tested using case studies and plan-do-study-act cycles. RESULTS: One of the cohort hospitals piloted the curriculum and tools, training 48 physicians, nurses, executives, and other allied health professionals. Pretest to posttest scores improved from an average of 82.7% to 90.2%. Survey feedback was favorable with 100% of respondents noting that they strongly agree or agree that attending this educational activity increased or improved their competency, performance, and patient outcomes. CONCLUSIONS: Initial testing suggests that the developed curriculum is empowering for frontline clinicians. Materials are available in an electronic format on the SPS external website. As member hospitals implement these materials, they will be evaluating learner satisfaction and provider usage. SPS will seek out feedback from these hospitals to further develop the materials and support clinicians.

Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model.

OBJECTIVE: Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator. METHODS: A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded. RESULTS: Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001). CONCLUSIONS: In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

Focused Training for the Handover of Critical Patient Information During Simulated Pediatric Emergencies.

OBJECTIVES: Miscommunication has been implicated as a leading cause of medical errors, and standardized handover programs have been associated with improved patient outcomes. However, the role of structured handovers in pediatric emergencies remains unclear. We sought to determine if training with an airway, breathing, circulation, situation, background, assessment, recommendation handover tool could improve the transmission of essential patient information during multidisciplinary simulations of critically ill children. METHODS: We conducted a prospective, randomized, intervention study with first-year pediatric residents at a quaternary academic children's hospital. Baseline and second handovers were recorded for residents in the intervention group (n = 12) and residents in the control group (n = 8) during multidisciplinary simulations throughout the academic year. The intervention group received handover education after baseline handover observation and a cognitive aid before second handover observation. Audio-recorded handovers were scored by using a Delphi-developed assessment tool by a blinded rater. RESULTS: There was no difference in baseline handover scores between groups (P = .69), but second handover scores were significantly higher in the intervention group (median 12.5 [interquartile range 12-13] versus median 7.5 [interquartile range 6-8] in the control group; P < .01). Trained residents were more likely to include a reason for the call (P < .01), focused history (P = .02), and summative assessment (P = .03). Neither timing of the second observation in the academic year nor duration between first and second observation were associated with the second handover scores (both P > .5). CONCLUSIONS: Structured handover training and provision of a cognitive aid may improve the inclusion of essential patient information in the handover of simulated critically ill children.

Neonatology faculty development using simulation.

The goal of faculty development activities is to supply the public with knowledgeable, skilled, and competent physicians who are prepared for high performance in the dynamic and complex healthcare environment. Current faculty development programs lack evidence-based support and are not sufficient to meet the professional needs of practicing physicians. Simulation activities for faculty development offer an alternative to traditional, teacher-centric educational offerings. Grounded in adult learning theory, simulation is a learner-centric, interactive, efficient, and effective method to train busy professionals. Many of the faculty development needs of clinical neonatologists can be met by participating in simulation-based activities that focus on technical skills, teamwork, leadership, communication, and patient safety.

Kinetic therapy improves oxygenation in critically ill pediatric patients.

OBJECTIVE: To compare changes in oxygenation after manual turning and percussion (standard therapy) and after automated rotation and percussion (kinetic therapy). DESIGN: Randomized crossover trial. SETTING: General and cardiac pediatric intensive care units. PATIENTS: Intubated and mechanically ventilated pediatric patients who had an arterial catheter and no contraindications to using a PediDyne bed. INTERVENTIONS: Patients were placed on a PediDyne bed (Kinetic Concepts) and received 18 hrs blocks of standard and kinetic therapy in an order determined by randomization. MEASUREMENTS AND MAIN RESULTS: Arterial blood gases were measured every 2 hrs during each phase of therapy. Oxygenation index and arterial-alveolar oxygen tension difference [P(A-a)O(2)] were calculated. Indexes calculated at baseline and after each 18-hr phase of therapy were analyzed. Fifty patients were enrolled. Data from 15 patients were either not collected or not used due to reasons that included violation of protocol and inability to tolerate the therapies in the study. Indexes of oxygenation were not normally distributed and were compared using Wilcoxon signed rank testing. Both therapies led to improvements in oxygenation, but only those from kinetic therapy achieved statistical significance. In patients receiving kinetic therapy first, median oxygenation index decreased from 7.4 to 6.19 (p = .015). The median P(A-a)O(2) decreased from 165.2 to 126.4 (p = .023). There were continued improvements in oxygenation after the subsequent period of standard therapy, with the median oxygenation index decreasing to 5.52 and median P(A-a)O(2) decreasing to 116.0, but these changes were not significant (p = .365 and .121, respectively). When standard therapy was first, the median oxygenation index decreased from 8.83 to 8.71 and the median P(a-a)o(2) decreased from 195.4 to 186.6. Neither change was significant. Median oxygenation index after the subsequent period of kinetic therapy was significantly lower (7.91, p = .044) and median P(A-a)O(2) trended lower (143.4, p = .077). CONCLUSIONS: Kinetic therapy is more efficient than standard therapy at improving oxygenation and produces improvements in oxygenation that are more persistent.

Every breath you take.

Recent advancements to ventilators and interface choices have increased noninvasive positive pressure ventilation usage in long-term and intensive care settings.

Reliability and validity of a scoring instrument for clinical performance during Pediatric Advanced Life Support simulation scenarios.

AIM: To assess the reliability and validity of scoring instruments designed to measure clinical performance during simulated resuscitations requiring the use of Pediatric Advanced Life Support (PALS) algorithms. METHODS: Pediatric residents were invited to participate in an educational trial involving simulated resuscitations that employ PALS algorithms. Each subject participated in a session comprised of four scenarios (asystole, dysrhythmia, respiratory arrest, shock). Video-recorded sessions were independently reviewed and scored by four raters using instruments designed to measure performance in terms of timing, sequence, and quality. Validity was assessed by two-factor analysis of variance with postgraduate year (PGY-1 versus PGY-2) as an independent variable. Reliability was assessed by calculation of overall interrater reliability (IRR) as well as a generalizability study to estimate variance components of individual measurement facets (scenarios, raters) and associated interactions. RESULTS: 20 subjects were scored by four raters. Based on a two-factor ANOVA, PGY-2s outperformed PGY-1s (p<0.05); significant differences in difficulty existed between the four scenarios, with dysrhythmia scores being the lowest. Overall IRR was high (0.81) and most variance could be attributed to subject (17%), scenario (13%), and the interaction between subject and scenario (52%); variance attributable to rater was minimal (1.4%). CONCLUSIONS: The instruments assessed in this study measure clinical performance during PALS scenarios in a reliable and valid manner. Measurement error could be minimized further through the use of additional scenarios but additional raters, for a given scenario, would not improve reliability. Further studies should assess validity of measurement with respect to actual clinical performance during resuscitations.