Clinical Impact of the Introduction of Pediatric Intussusception Air Enema Reduction Technology in a Low- to Middle-Income Country Using Low-Cost Simulation-Based Medical Education.

INTRODUCTION: Pediatric intussusception is a common cause of bowel obstruction in infants. Air enema (AE) reduction is routine first-line management in many countries; however, there is a high rate of operative intervention in low- and middle-income countries. The aims of the study were to use simulation-based medical education with an intussusception simulator to introduce AE reduction to Myanmar and to assess its effect on provider behaviors and the resulting clinical care. METHODS: Clinical evaluation was conducted by comparing clinical outcomes data for children with intussusception 12 months before implementation with that from 12 months subsequent to implementation. These included the following: AE success rates, recurrence rates, length of stay, intestinal resection, and operative intervention rates. An educational workshop was developed that used a low-cost mannequin to facilitate practice at the reduction of intussusception using AE. Curriculum evaluation was performed through 5-point rating scale self-assessment in several domains. Data analysis was performed with Mann-Whitney U test, Student t test, or Wilcoxon signed-ranks test as appropriate; a P value of less than 0.05 was considered to be significant. RESULTS: After implementation, there was a significant reduction in the overall operative intervention rates [82.5% (85/103) vs. 58.7% (44/75), P = 0.006]. Intestinal resection rates increased [15.3% (13/85) vs. 35.9% (14/39), P = 0.02]. The success rate with attempted AE reduction was 94.4% (34/36), with a recurrence rate of 5.6% (2/36). The simulation-based medical education workshop was completed by 25 local participants. There was a significant difference in the confidence of performing (1.9 vs. 3.6, P ≤ 0.0001) or assisting (2.8 vs. 3.7, P = 0.018) an AE reduction before and after the workshop. CONCLUSIONS: Simulation-based educational techniques can be successfully applied in a low- and middle-income country to facilitate the safe introduction of new equipment and techniques with significant beneficial impact on provider behaviors and the resulting clinical care.

Establishing content validity and fidelity of a novel paediatric intussusception air enema reduction simulator.

BACKGROUND: Intussusception is a common, potentially life-threatening paediatric condition. Non-operative treatment with an air enema has been established as the clinical gold standard. There is no validated model for the training of this procedure. Our aim was to produce a novel air enema reduction simulator and validate its use as a training tool. METHODS: A low-cost paediatric intussusception air enema simulator was created. It was designed to include essential key clinical procedural steps. Participants included both procedural experts and novices from the Departments of Paediatric Radiology and Surgery. The simulator was assessed for face and content validity and its physical, conceptual and experiential fidelity by a structured questionnaire using a 5-point Likert's scale. Statistical analysis included a t-test, and a P-value of <0.05 was considered significant. RESULTS: Twenty-four clinicians completed the simulation activity (expert: 13 and novices: 11). All experts had performed a minimum of 40 clinical procedures, and 46% had performed >50 procedures. All scores were favourable in all domains for face and content validity: 3.5 (physical appearance), 3.3 (insertion of the tube and taping), 3.1 (holding of the buttocks) and 3.5 (performing the air enema). The simulator also scored highly with fidelity assessment; visual 3.5, conceptual 3.4. There was no difference in procedural confidence with experts (3.8 versus 3.6, P = 0.28), but there was for novices (1.0 versus 2.9, P = 0.0002). CONCLUSIONS: This low-cost air enema reduction simulator for intussusception has an excellent educational potential for use in a training program in a tertiary centre, as well as, resource-constrained environments.