The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Cost-effectiveness analysis of workplace-based distributed cardiopulmonary resuscitation training versus conventional annual basic life support training.

Context: Although distributed cardiopulmonary resuscitation (CPR) practice has been shown to improve learning outcomes, little is known about the cost-effectiveness of this training strategy. This study assesses the cost-effectiveness of workplace-based distributed CPR practice with real-time feedback when compared with conventional annual CPR training. Methods: We measured educational resource use, costs, and outcomes of both conventional training and distributed training groups in a prospective-randomised trial conducted with paediatric acute care providers over 12 months. Costs were calculated and reported from the perspective of the health institution. Incremental costs and effectiveness of distributed CPR training relative to conventional training were presented. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER) if appropriate. One-way sensitivity analyses and probabilistic sensitivity analysis were conducted. Results: A total of 87 of 101 enrolled participants completed the training (46/53 in intervention and 41/48 in the control). Compared with conventional training, the distributed CPR training group had a higher proportion of participants achieving CPR excellence, defined as over 90% guideline compliant for chest compression depth, rate and recoil (control: 0.146 (6/41) vs intervention 0.543 (25/46), incremental effectiveness: +0.397) with decreased costs (control: $C266.50 vs intervention $C224.88 per trainee, incremental costs: -$C41.62). The sensitivity analysis showed that when the institution does not pay for the training time, distributed CPR training results in an ICER of $C147.05 per extra excellent CPR provider. Conclusion: Workplace-based distributed CPR training with real-time feedback resulted in improved CPR quality by paediatric healthcare providers and decreased training costs, when training time is paid by the institution. If the institution does not pay for training time, implementing distributed training resulted in better CPR quality and increased costs, compared with conventional training. These findings contribute further evidence to the decision-making processes as to whether institutions/programmes should financially adopt these training programmes.

Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers - A randomized controlled trial.

OBJECTIVES: Guideline compliant CPR is associated with improved survival for patients with cardiac arrest. Conventional Basic Life Support (BLS) training results in suboptimal CPR competency and skill retention. We aimed to compare the effectiveness of distributed CPR training with real-time feedback to conventional BLS training for CPR skills in pediatric healthcare providers. METHODS: Healthcare providers were randomized into receiving annual BLS training (control) or distributed training with real-time feedback (intervention). The intervention group was asked to practice CPR for 2 min on mannequins while receiving real-time CPR feedback, at least once per month. Control group participants were not asked to practice CPR during the study period. Excellent CPR was defined as 90% guideline-compliance for depth, rate and recoil of chest compressions. CPR performance of participants was assessed (on infant and adult-sized mannequins) every 3 months for a duration of 12 months. CPR performance was compared between the 2 groups. RESULTS: A total of 87 healthcare providers were included in the analyses (control n = 41, intervention n = 46). Baseline assessment showed no significant difference in CPR performance across the 2 groups. The intervention group has a significantly greater proportion of participants with excellent CPR compared with the control group on an adult sized mannequin (14.6% vs. 54.3%, p < 0.001) and infant-sized mannequin (19.5% vs. 71.7%, p < 0.001) at the end of the study. In the intervention group, all CPR metrics except infant depth were improved and retained over the course of the study. CONCLUSION: Distributed CPR training with real-time feedback improves the compliance of AHA guidelines of quality of CPR.

Cognitive Load Theory for debriefing simulations: implications for faculty development.

The debriefing is an essential component of simulation-based training for healthcare professionals, but learning this complex skill can be challenging for simulation faculty. There are multiple competing priorities for a debriefer's attention that can contribute to a high mental workload, which may adversely affect debriefer performance and consequently learner outcomes. In this paper, we conceptualize the debriefer as a learner of debriefing skills and we discuss Cognitive Load Theory to categorize the many potential mental loads that can affect the faculty debriefer as learner. We then discuss mitigation strategies that can be considered by faculty development programmes to enhance professional development of debriefing staff.

Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention.

OBJECTIVES: To measure the effect of a 1-day team training course for pediatric interprofessional resuscitation team members on adherence to Pediatric Advanced Life Support guidelines, team efficiency, and teamwork in a simulated clinical environment. DESIGN: Multicenter prospective interventional study. SETTING: Four tertiary-care children's hospitals in Canada from June 2011 to January 2015. SUBJECTS: Interprofessional pediatric resuscitation teams including resident physicians, ICU nurse practitioners, registered nurses, and registered respiratory therapists (n = 300; 51 teams). INTERVENTIONS: A 1-day simulation-based team training course was delivered, involving an interactive lecture, group discussions, and four simulated resuscitation scenarios, each followed by a debriefing. The first scenario of the day (PRE) was conducted prior to any team training. The final scenario of the day (POST) was the same scenario, with a slightly modified patient history. All scenarios included standardized distractors designed to elicit and challenge specific teamwork behaviors. MEASUREMENTS AND MAIN RESULTS: Primary outcome measure was change (before and after training) in adherence to Pediatric Advanced Life Support guidelines, as measured by the Clinical Performance Tool. Secondary outcome measures were as follows: 1) change in times to initiation of chest compressions and defibrillation and 2) teamwork performance, as measured by the Clinical Teamwork Scale. Correlation between Clinical Performance Tool and Clinical Teamwork Scale scores was also analyzed. Teams significantly improved Clinical Performance Tool scores (67.3-79.6%; p < 0.0001), time to initiation of chest compressions (60.8-27.1 s; p < 0.0001), time to defibrillation (164.8-122.0 s; p < 0.0001), and Clinical Teamwork Scale scores (56.0-71.8%; p < 0.0001). A positive correlation was found between Clinical Performance Tool and Clinical Teamwork Scale (R = 0.281; p < 0.0001). CONCLUSIONS: Participation in a simulation-based team training educational intervention significantly improved surrogate measures of clinical performance, time to initiation of key clinical tasks, and teamwork during simulated pediatric resuscitation. A positive correlation between clinical and teamwork performance suggests that effective teamwork improves clinical performance of resuscitation teams.

Simulation in the clinical setting: towards a standard lexicon.

Simulation-based educational activities are happening in the clinical environment but are not all uniform in terms of their objectives, delivery, or outputs. While these activities all provide an opportunity for individual and team training, nuances in the location, timing, notification, and participants impact the potential outcomes of these sessions and objectives achieved. In light of this, there are actually many different types of simulation-based activity that occur in the clinical environment, which has previously all been grouped together as "in situ" simulation. However, what truly defines in situ simulation is how the clinical environment responds in its' natural state, including the personnel, equipment, and systems responsible for care in that environment. Beyond individual and team skill sets, there are threats to patient safety or quality patient care that result from challenges with equipment, processes, or system breakdowns. These have been labeled "latent safety threats." We submit that the opportunity for discovery of latent safety threats is what defines in situ simulation and truly differentiates it from what would be more rightfully called "on-site" simulation. The distinction between the two is highlighted in this article, as well as some of the various sub-types of in situ simulation.

An Approach to Confederate Training Within the Context of Simulation-Based Research.

STATEMENT: Simulation-based education often relies on confederates, who provide information or perform clinical tasks during simulation scenarios, to play roles. Although there is experience with confederates in their more routine performance within educational programs, there is little literature on the training of confederates in the context of simulation-based research. The CPR CARES multicenter research study design included 2 confederate roles, in which confederates' behavior was tightly scripted to avoid confounding primary outcome measures. In this report, we describe our training process, our method of adherence assessment, and suggest next steps regarding confederate training scholarship.

The Past, Present, and Future of Simulation-based Education for Pediatric Emergency Medicine.

The pediatric emergency medicine (PEM) environment is well suited for simulation-based activities, be they educational interventions for PEM learners, evaluations of the interface between health providers and the environment that they work in, or research investigations using simulation as a tool to answer specific clinical questions. As such, PEM has been among the leaders in the integration of this modality for clinical training. Traditionally, simulation has been used extensively for the dissemination of clinical training in the areas of clinical knowledge and its application, and the clinical, technical, and teamwork skills involved in PEM care. Increasingly, simulation is being used in novel applications, including breaking bad news, disclosure of error, family-centered care, quality and patient safety education, and system-level integration. The future will look to further identify, measure, and inform the integration of simulation with new and innovative adjuncts in the clinical environment, as well as to determine the optimal timing and use of simulation-based education to enhance the quality of care delivered to patients by the interprofessional and multidisciplinary team.

A simulation-based intervention teaching seizure management to caregivers: A randomized controlled pilot study.

OBJECTIVES: To examine the effect of simulation-based seizure management teaching on improving caregiver competence and reported confidence with managing seizures. The authors hypothesized that simulation-based education would lead to a higher level of demonstrated competence and reported confidence in family members and caregivers. Simulation has not been previously studied in this context. METHODS: A two-group pre- and post-test experimental research design involving a total of 61 caregivers was used. The intervention was a simulation-based seizure curriculum delivered as a supplement to traditional seizure discharge teaching. Caregiver performance was analyzed using a seizure management checklist. Caregivers' perception of self-efficacy was captured using a self-efficacy questionnaire. RESULTS: Caregivers in the experimental group achieved significantly higher postintervention performance scores than caregivers in the control group in both premedication and postmedication seizure management (P<0.01). Additionally, they achieved significantly higher scores on the self-efficacy questionnaire including items reflecting confidence managing the seizure at home (P<0.05). CONCLUSION: Caregivers receiving the supplemental simulation-based curriculum achieved significantly higher levels of competence and reported confidence, supporting a positive relationship between simulation-based seizure discharge education, and caregiver competence and confidence in managing seizures. Simulation sessions provided insight into caregiver knowledge but, more importantly, insight into the caregiver's ability to apply knowledge under stressful conditions, allowing tailoring of curriculum to meet individual needs. These findings may have applications and relevance for management of other acute or chronic medical conditions.

OBJECTIFS: Examiner l'effet de l'enseignement de la prise en charge des convulsions par simulation pour améliorer les compétences des soignants et leur confiance déclarée à traiter les convulsions. Les auteurs postulent que l'enseignement par simulation accroîtrait les compétences démontrées et la confiance déclarée des membres de la famille et des soignants. La simulation n'a jamais été étudiée dans ce contexte. MÉTHODOLOGIE: Une méthodologie de recherche expérimentale en deux groupes avant et après le test a été privilégiée auprès de 61 soignants. L'intervention consistait en un cours par simulation sur les convulsions donné en plus de l'enseignement habituel sur les convulsions présenté au congé. Le rendement des soignants a été analysé au moyen d'une liste de vérification de la prise en charge des convulsions. La perception d'auto-efficacité du soignant a été saisie au moyen d'un questionnaire d'auto-efficacité. RÉSULTATS: Les soignants du groupe expérimental ont obtenu des indices de rendement considérablement plus élevés après l'intervention que ceux du groupe témoin, tant avant qu'après la prise en charge des convulsions par médication (P<0,01). De plus, ils ont obtenu des indices considérablement plus élevés au questionnaire d'auto-efficacité, y compris les questions reflétant la confiance à soigner les convulsions à domicile (P<0,05). CONCLUSION: Les soignants qui avaient eu un cours par simulation ont obtenu des taux de compétence et de confiance déclarée beaucoup plus élevés. Ces résultats corroborent la relation positive entre l'enseignement sur les convulsions par simulation au congé et la compétence et la confiance des soignants envers la prise en charge des convulsions. Les séances de simulation donnaient un aperçu des compétences des soignants, mais, surtout, de leur capacité à appliquer leurs connaissances dans des conditions stressantes, ce qui permet d'adapter le cours à leurs besoins. Ces observations peuvent être utiles et pertinentes pour la prise en charge d'autres maladies aiguës ou chroniques.

The development and assessment of an evaluation tool for pediatric resident competence in leading simulated pediatric resuscitations.

INTRODUCTION: It is critical that competency in pediatric resuscitation is achieved and assessed during residency or post graduate medical training. The purpose of this study was to create and evaluate a tool to measure all elements of pediatric resuscitation team leadership competence. METHODS: An initial set of items, derived from a literature review and a brainstorming session, were refined to a 26 item assessment tool through the use of Delphi methodology. The tool was tested using videos of standardized resuscitations. A psychometric assessment of the evidence for instrument validity and reliability was undertaken. RESULTS: The performance of 30 residents on two videotaped scenarios was assessed by 4 pediatricians using the tool, with 12 items assessing 'leadership and communication skills' (LCS) and 14 items assessing 'knowledge and clinical skills' (KCS). The instrument showed evidence of reliability; the Cronbach's alpha and generalizability co-efficients for the overall instrument were α=0.818 and Ep(2)=0.76, for LCS were α=0.827 and Ep(2)=0.844, and for KCS were α=0.673 and Ep(2)=0.482. While validity was initially established through literature review and brainstorming by the panel of experts, it was further built through the high strength of correlation between global scores and scores for overall performance (r=0.733), LCS (r=0.718) and KCS (r=0.662) as well as the factor analysis which accounted for 40.2% of the variance. CONCLUSION: The results of the study demonstrate that the instrument is a valid and reliable tool to evaluate pediatric resuscitation team leader competence.

A comparison of two mechanisms of severe paediatric injury in northern Israel.

BACKGROUND: An increased incidence of severe injury due to falls from buildings (FFB) is reported in the rural area of northern Israel. This makes FFB, and motor vehicle collision (MVC) the two leading causes of severe paediatric trauma. METHODS: A single-centre, age-sex matched comparison analysis of the two mechanisms of injury was conducted. Children involved in MVC (study subjects) or FFB (controls), who were brought by the Emergency Medical System Mobile-Intensive-Care-Unit from the field to the trauma bay of the Emergency Department (ED) were enrolled on the basis of a convenience sample. Immediately following ED admission, heart rate (HR), systolic blood pressure (SBP), and base deficit (BD) were recorded. Types of injuries, Glasgow Coma Score (GCS) on scene, and Injury Severity Score (ISS) were also obtained. RESULTS: Eleven study subjects and 22 controls were enrolled during a 1-year period. The mean ISS for the study subjects group and for the controls was 23.4 and 19.5, respectively. No difference was found in comparing the ISS, BD, SBP and HR of the two groups (p=0.261, p=0.421, p=0.314, and p=0.824, respectively). Controls had a lower GCS (p<0.031) and were more likely to have a skull fracture (p<0.0082). Study subjects were more likely to have limb injuries (p<0.0001) and thoracoabdominal injuries (p<0.0059). CONCLUSIONS: This study suggests that the Injury Severity Score of the two mechanisms of paediatric injury is high. The haemodynamic characteristics on ED admission were comparable between the two groups of patients but the likelihood of specific type of injury was different.

Simulation in paediatrics: An educational revolution.

Recent changes in the culture of medical education have highlighted deficiencies in the traditional apprenticeship model of education, and emphasized the need for more experiential modalities of learning. Simulations, which are scenarios or environments designed to closely approximate real-world situations, have recently found their way into the medical training of health care providers. High-fidelity simulators are life-like mannequins connected to computer systems that control the physiological and physical responses of the mannequin. These simulators are able to provide direct feedback to learners in safe, risk-free environments. This technology has been used to teach all aspects of medical care, including medical knowledge, technical skills, and behavioural training or communication skills. The present article provides a general overview of simulation that will hopefully help to generate interest in paediatric simulation across Canada. Several tertiary care paediatric hospitals in Canada are already using simulation to teach health care providers; continued growth and interest is expected in this exciting area of medical education.

Factors influencing childhood influenza immunization.

Following the launch of a publicly funded influenza immunization program for all residents of Ontario over the age of 6 months, we evaluated 203 parents of children who presented to our emergency department between January and March of the following year (2001). Overall, 54 (27%) of the children had been vaccinated. Parents of non-immunized children were more likely to believe that immunization resulted in a flu-like illness (42% v. 17%; p = 0.001), caused side effects that were more severe than having influenza (36% v. 17%; p = 0.010) and weakened the immune system (52% v. 24%; p < 0.001). Parents of both immunized and non-immunized children incorrectly identified gastrointestinal symptoms as symptoms of influenza. The primary reason for deciding against immunization was the belief that their child was not at risk. After adjustment, children with a chronic disease were more likely than those without a chronic disease to be immunized (adjusted odds ratio [OR] 4.7, 95% confidence interval [CI] 1.8-12.6). Children of parents who discussed immunization with a physician were more likely to be immunized than those who had not discussed immunization with a physician (OR 6.8, 95% CI 2.4-19.2).