A national survey of American Pediatric Anesthesiologists: patient-controlled analgesia and other intravenous opioid therapies in pediatric acute pain management.

BACKGROUND: The influence of patient characteristics, institutional demographics, and published practice guidelines on the provision of IV opioid analgesia, particularly as delivered through a patient-controlled analgesia (PCA) delivery device, to pediatric patients is unknown. METHODS: We sent a national, web-based, descriptive survey of pediatric pain management practice to select members of the Society for Pediatric Anesthesia to assess institutional demographics, availability and implementation of IVPCA and PCA by proxy, and recalled occurrence of serious and life-threatening opioid-related side effects. RESULTS: Data from respondents at 252 institutions throughout the United States were collected and analyzed. Sixty-nine percent of respondents practiced in a children's hospital or children's center within a general hospital, and 51% of institutions had a pediatric pain service. Virtually all pediatric pain services (91%) were administered by departments of anesthesiology. Pediatric pain service availability correlated with the number of pediatric beds. IVPCA was available to pediatric patients at 96% of institutions surveyed, whereas IVPCA by proxy was available at only 38%. Eleven percent of respondents reported that their hospital no longer provided IVPCA by proxy as a result of the 2004 Joint Commission on Accreditation of Hospitals Sentinel Event Warning. Instructional material concerning IVPCA was provided to patients or their families by 40% of institutions. IVPCA orders were handwritten by 55% of respondents, despite 39% having computerized provider order entry systems. Ninety percent of respondents reported using pulse oximetry monitoring when patients were administered IVPCA. Forty-two respondents recalled patients having received naloxone to counteract the cardiopulmonary side effects of opioids during the year before receipt of the survey. Eight respondents recalled patient deaths having occurred over the past 5 years in patients receiving IVPCA, IVPCA by proxy, and continuous non-IVPCA opioid infusions. CONCLUSIONS: Although IVPCA was available to pediatric patients at most institutions surveyed, prescribing practices and supervision of pediatric pain management were influenced by patient characteristics, institutional demographics, and published national guidelines. Recalled life-threatening events were reported in conjunction with all modes of opioid infusion therapy. Interventions that might diminish the incidence of adverse events but are not used to their fullest extent include improved education and implementation of systems designed to minimize human error involved in the prescribing of opioids. Providing a more accurate accounting of complications would require institutions to participate in a prospective data-collecting consortium designed to track both the incidence of therapy and associated complications.

Residents' mental model of bag-mask ventilation.

OBJECTIVES: Our objectives were to characterize resident knowledge of bag-mask ventilation (BMV) and to identify predictors of a well-developed mental model of BMV. METHODS: A pilot survey of airway experts identified 6 steps considered essential in situations of difficult BMV. Subsequently, residents from pediatric, emergency medicine, and medicine-pediatric programs at a tertiary care hospital completed the same pediatric scenario-based item given to airway experts. RESULTS: Of all surveys, 75% (n = 103) were completed. No resident identified all 6 maneuvers for difficult BMV. With decreasing frequency, the items identified were as follows: reposition patient/airway (82%), oral airway (61%), nasal airway (39%), jaw thrust (37%), 2-person technique (7%), and call for help (4%). Emergency medicine residents had a higher mean (SD) score than the medicine-pediatric and pediatric residents of a possible 6 (2.71 (1.26) vs 2.01 (1.07), P = 0.004) and were significantly more likely to identify certain maneuvers: oral airway (81% vs 52%, P = 0.006), nasal airway (57% vs 29%, P = 0.006), and 2-person technique (14% vs 3%, P = 0.042). Only 15% of all residents were able to identify 4 or more essential maneuvers. Higher level of training was associated with identifying the 2-person technique. In addition, residents who completed 1 month of pediatric or adult anesthesia were more likely to identify use of nasal airway, oral airway and 2-person technique, and to identify 4 or more maneuvers. CONCLUSIONS: Emergency medicine residents identified more steps to optimize difficult BMV, although most residents exhibited a poorly developed mental model for difficult BMV compared with the consistent mental model of airway experts. Future research should investigate strategies for improving residents' mental model of BMV and its impact on patient care.

A survey of anesthesiologists' knowledge of American Heart Association Pediatric Advanced Life Support Resuscitation Guidelines.

AIM OF STUDY: Determine anesthesiologists' knowledge of the 2005 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) recommendations. METHODS: After obtaining institutional review board approval, a survey was sent in February 2007 to members of the Society for Pediatric Anesthesia via a web-based survey tool, and re-sent to nonresponders five times over the following 7 months. RESULTS: Overall response rate was 51% (389/768 members). Eighty-five percent of respondents had pediatric anesthesia fellowships, 71% provided anesthesia primarily to children, 71% had been in practice >10 years, 29% had PALS or APLS training during the previous year, and 37% had a patient requiring chest compressions in the previous year. Overall, 89% of respondents knew the correct initial dose of epinephrine (adrenaline) for asystole, 44% knew subsequent management for asystole if initial epinephrine dose was ineffective, 49% knew defibrillation sequence to treat pulseless ventricular tachycardia (VT), and 73% knew the medication sequence to treat pulseless VT. Only those respondents who reported to be in practice for >10 years scored significantly (p<0.0001) better on all resuscitation treatment questions. Respondents who had PALS or APLS training in the previous year or previous 2 years scored significantly better on the defibrillation sequence for pulseless VT (p=0.001 and p=0.045, respectively), and the medication sequence for pulseless VT (p=0.0005 and p=0.011, respectively) when compared with those who had no previous training. CONCLUSION: Deficiencies exist in the knowledge of current AHA PALS guidelines among anesthesiologists. Formal resuscitation training programs should be considered in ongoing continuing medical education.

The daily goals communication sheet: a simple and novel tool for improved communication and care.

This tool directs the health care team to discuss specific goals of care and best-practice safety measures daily for each patient and to ensure goal understanding and implementation.

Lightning, sudden cardiac death, simulation and an automated external defibrillator: the perfect storm.

This is a report of an 11-year-old boy who had sudden cardiac death after a lightning strike while playing lacrosse at summer camp. The camp staff had performed weekly drills to prepare for various medical emergencies and quickly activated their "Emergency Activation System". The child received immediate cardiopulmonary resuscitation (CPR) and was defibrillated with an automated defibrillator (AED) within 3 min of becoming pulseless and was ultimately resuscitated after being defibrillated three times. A community ambulance with a defibrillator on board did not arrive until several minutes after the on-site team had achieved return of spontaneous circulation. In this report, we describe the clinical course of this patient; briefly review lightning injuries, other causes of sudden cardiac death in children and use of AEDs. Finally, we review how simulation has been used in this case and others as a mechanism to ensure preparedness for medical emergencies. This child is alive and well today because of these well-trained camp counselors. Their system of using simulation to maintain emergency readiness serves as an example for lay and professional medical providers alike.

Simulation in medicine: addressing patient safety and improving the interface between healthcare providers and medical technology.

Medicine, as an industry in which human lives depend on the skill and performance of operators, must create and maintain a culture of safety, in addition to promoting the design of systems to mitigate errors. The use of medical simulation as a mechanism for training healthcare professionals in a safe environment is expanding rapidly. An important component of systems that ensure the safety of patients in the hospital setting is the interface between humans and technology in the hospital. The objective of this paper is to review: (1) the definition and a brief history of medical simulation, (2) examples of how current medical simulation centers are using simulation to address patient safety, and (3) examples of how simulation can be used to enhance patient safety through improvement of the interface between healthcare practitioners and medical technology. Medical simulation and human factors engineering can be used to examine and enhance the interface between healthcare practitioners and medical technology, with the potential to make a significant contribution to patient safety.

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.

BACKGROUND: The quality of life support delivered during cardiopulmonary resuscitation affects outcomes. However, little data exist regarding the quality of resuscitation delivered to children and factors associated with adherence to American Heart Association (AHA) resuscitation guidelines. PARTICIPANTS: Pediatric residents from an academic, tertiary care hospital. DESIGN: Prospective, observational cohort study of residents trained in the AHA PALS 2000 guidelines managing a high-fidelity mannequin simulator programmed to develop pulseless ventricular tachycardia (PVT). MAIN OUTCOME MEASURES: Proportion of residents who: (1) started compressions in < or =1min from onset of PVT, (2) defibrillated in < or =3min and (3) factors associated with time to defibrillation. RESULTS: Seventy of eighty (88%) residents participated. Forty-six of seventy (66%) failed to start compressions within 1min of pulselessness and 23/70 (33%) never started compressions. Only 38/70 (54%) residents defibrillated the mannequin in < or =3min of onset of PVT. There was no significant difference in time elapsed between onset of PVT and defibrillation by level of post-graduate training. However, residents who had previously discharged a defibrillator on either a patient or a simulator compared to those who had not were 87% more likely to successfully defibrillate the mannequin at any point in time (hazard ratio 1.87, 95% CI: 1.08-3.21, p=0.02). CONCLUSIONS: Pediatric residents do not meet performance standards set by the AHA. Future curricula should focus training on identified defects including: (1) equal emphasis on "airway and breathing" and "circulation" and (2) hands-on training with using and discharging a defibrillator in order to improve safety and outcomes.

Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario.

INTRODUCTION: Supraventricular tachycardia (SVT) is the most frequent tachydysrhythmia in children. SVT with hemodynamic compromise should be terminated by immediate electrical cardioversion. Study objectives were to: (1) establish time to recognition and cardioversion of simulated unstable SVT; and (2) document delays and mistakes made during cardioversion. METHODS: Ten teams of pediatric residents were presented with an unresponsive "patient" (Laerdal SimMan) in unstable SVT. Actions of team members and simulator timestamps of key events were recorded. A retrospective review of events and time logs was performed with primary outcome measure of time to successful cardioversion. RESULTS: Median time to cardioversion was 8.9 minutes (range, 5.3 minutes to unsuccessful scenario terminated at 15 minutes). In 20% of scenarios, the patient was never cardioverted. Ninety percent of teams administered adenosine, but 44% of attempts demonstrated incorrect administration technique. Other maneuvers before cardioversion: 70% administered fluid, 60% attempted vagal maneuvers, 30% requested electrocardiogram, 30% requested antiarrhythmics. In 20% of scenarios, the rhythm was misidentified. When cardioversion was performed, 25% failed to use gel, 37.5% failed to synchronize, 25% used inappropriate energy doses. In 60% of scenarios, no oxygen was administered. In 90% there was no assignment of Glasgow Coma Scale, and no assessment of mental status in 30%. In 60% perfusion was not assessed. CONCLUSIONS: Median time to cardioversion of 8.9 minutes is inconsistent with AHA recommendations for treatment of unstable SVT with "immediate cardioversion." Delays were secondary to lack of recognition of "unstable" SVT, due to failure to assess perfusion and mental status. Errors encountered during simulation identify curriculum reform targets.

The use of cognitive AIDS during simulated pediatric cardiopulmonary arrests.

BACKGROUND: Management of pediatric cardiopulmonary arrest (CPA) is challenging because of the low volume of experience of most pediatric health care providers. Use of cognitive aids may assist in making rapid decisions in these crises; however, there are no known published reports on whether these aids are actually used during arrest management and whether they impact quality of care. METHODS: Sixty pediatric residents participated in individual simulated CPA scenarios, which involved pulseless ventricular tachycardia and pulseless electrical activity. Our primary outcome measure was the proportion of pediatric residents who used cognitive aids during simulated CPAs. Secondary outcome measures were to quantify 1) type of aids used, 2) category of use, and 3) human errors made during resuscitation efforts. RESULTS: Eighty-five percent of residents voluntarily used a cognitive aid to assist in managing simulated pediatric CPAs. The most commonly used aids were an American Heart Association Pediatric Advanced Life Support aid and an institutionally created aid. Forty-three of 51 (84.3%) and 23 of 46 (60.5%) residents used these aids for assistance with the pulseless ventricular tachycardia and pulseless electrical activity algorithm, respectively. Unfortunately, 13 of 51 (25.5%) residents chose the incorrect treatment algorithm, resulting in inappropriate management. CONCLUSION AND APPLICATION: Although the majority of residents chose to use cognitive aids for assistance, errors in management were common. Further study is required to determine whether these errors are associated with cognitive aid design flaws and whether improving their design through human factors research can help minimize errors in Basic and Advanced Life Support, ultimately improving patient outcomes.

Simulation: translation to improved team performance.

Traditional medical education has emphasized autonomy, and until recently issues related to teamwork have not been explicitly included in medical curriculum. The Institute of Medicine highlighted that health care providers train as individuals, yet function as teams, creating a gap between training and reality and called for the use of medical simulation to improve teamwork. The aviation industry created a program called Cockpit and later Crew Resource Management that has served as a model for team training programs in medicine. This article reviews important concepts related to teamwork and discusses examples where simulation either could be or has been used to improve teamwork in medical disciplines to enhance patient safety.