Debriefing Trainees After Global Health Experiences: An Expert Consensus Delphi Study.

BACKGROUND: Global health (GH) opportunities in pediatric residencies are prevalent. Debriefing trainees after a GH experience is a tool to optimize educational processing, identify post-return stressors, and facilitate coping skills; however, there are no consensus recommendations for debriefing in this context. OBJECTIVE: Our objective was to develop structure and content guidelines for standardized debriefing of residents returning from short-term clinical GH rotations abroad. METHODS: Through a modified Delphi methodology, we developed a standardized consensus-based debriefing tool. Eleven pediatric GH education experts were recruited. Experts were individuals with leadership experience in GH education who demonstrated academic engagement by either primary or senior authorship of a publication or relevant presentation at a conference. The expert panel (EP) completed 4 surveys that were amended after each round based on qualitative data, which was assessed for emergent themes. In the final round, the EP rated each consensus recommendation in importance using a 4-point Likert scale. RESULTS: Ten of the 11 panelists completed all study rounds. The EP achieved consensus that residents should complete post-return debriefing and rated 32 consensus recommendations in importance. Twelve recommendations were deemed "essential"; these debriefing recommendations focused on timing and preparation, reflection and feedback, trainee well-being and coping skills, ethical concerns, and the need to provide mental health support and resources for trainees with psychological distress. CONCLUSIONS: According to GH experts, all residents who participate in GH experiences should participate in a post-return debrief. Thirty-two consensus recommendations regarding content, timing, structure, and actions for post-return debriefing were formulated.

Rapid Cycle Deliberate Practice Improves Retention of Pediatric Resuscitation Skills Compared With Postsimulation Debriefing.

INTRODUCTION: Rapid cycle deliberate practice (RCDP) for teaching team-based resuscitation is associated with similar improvements in immediate performance as compared with postsimulation debriefing (PSD). Limited studies compare skill retention between these 2 modalities. Our objective was to compare retention of team leader performance in residents trained with RCDP versus PSD. METHODS: This was a cluster-randomized trial comparing RCDP and PSD from January 2018 to April 2019. Pediatric and emergency medicine residents participated in simulation-based pediatric resuscitation education, and teams were randomized to undergo either RCDP or PSD. Each participant's team leader performance was assessed 1 to 12 months after training via a simulated cardiac arrest. The primary outcome was time to defibrillation. Secondary outcomes included overall team leader performance and time to chest compressions. RESULTS: Thirty-two residents (90.6% pediatrics, 9.4% emergency medicine) met inclusion criteria (16 RCDP, 16 PSD). Of the 32 residents, 40% returned in 1 to 3 months, 25% 3 to 6 months, 16% 6 to 9 months, and 19% 10 to 12 months. Participants in RCDP had more than 5 times the odds of achieving defibrillation versus those in the PSD group (odds ratio = 5.57, 95% confidence interval = 1.13-27.52, P = 0.04). The RCDP group had a higher mean Resident Team Leader Evaluation score (0.54 ± 0.19) than the PSD group (0.34 ± 0.16, P < 0.001). CONCLUSIONS: This study shows significant differences in subsequent performance in the team leader trained with RCDP and suggests that RCDP may improve retention of pediatric resuscitation skills compared with PSD. Future studies should focus on best applications for RCDP with attention to knowledge and skill decay.

Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education.

BACKGROUND: The optimal structure of simulation to train teams to perform pediatric advanced life support (PALS) requires further research. Most simulation is structured with an uninterrupted scenario with postsimulation debriefing (PSD). Rapid-cycle deliberate practice (RCDP) is structured with a series of simulations with microdebriefing quickly switching within action targeting specific performance goals. OBJECTIVE: The objective was to compare team performance immediately after training, as well as learner workload, for teams trained using either PSD or RCDP. METHODS: In 2018-2019, a total of 41 interprofessional teams of 210 residents and nurses were recruited from 250 eligible participants (84%) and randomized into either arm (RCDP or PSD) teaching the same objectives of resuscitation of a patient in PEA arrest, in the same time frame. The structure of the simulation varied. Demographic surveys were collected before training, the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) was administered immediately after training to assess workload during training and performance was assessed immediately after training using a pulseless ventricular tachycardia arrest with the primary outcome being time to defibrillation. RESULTS: Thirty-nine teams participated over a 16-month time span. Performance of teams randomized to RCDP showed significantly better time to defibrillation, 100 s (95% confidence interval [CI] = 90-111), compared to PSD groups, 163 s (95% CI = 120-201). The workload of the groups also showed a lower total NASA-TLX score for the RCDP groups. CONCLUSIONS: For team-based time-sensitive training of PALS, RCDP outperformed PSD. This may be due to a reduction in the workload faced by teams during training.

Workload of learners during simulated paediatric cardiopulmonary resuscitation.

Introduction: Learner workload during simulated team-based resuscitations is not well understood. In this descriptive study, we measured the workload of learners in different team roles during simulated paediatric cardiopulmonary resuscitation. Methods: Paediatric emergency nurses and paediatric and emergency medicine residents formed teams of four to eight and randomised into roles to participate in simulation-based, paediatric resuscitation. Participant workload was measured using the NASA Task Load Index, which provides an average workload score (from 0 to 100) across six subscores: mental demand, physical demand, temporal demand, performance, frustration and mental effort. Workload is considered low if less than 40, moderate if between 40 and 60 and high if greater than 60. Results: There were 210 participants representing 40 simulation teams. 138 residents (66%) and 72 nurses (34%) participated. Team lead reported the highest workload at 65.2±10.0 (p=0.001), while the airway reported the lowest at 53.9±10.8 (p=0.001); team lead had higher scores for all subscores except physical demand. Team lead reported the highest mental demand (p<0.001), while airway reported the lowest. Cardiopulmonary resuscitation coach and first responder reported the highest physical demands (p<0.001), while team lead and nurse recorder reported the lowest (p<0.001). Conclusions: Workload for learners in paediatric simulated resuscitation teams was moderate to high and varied significantly based on team role. Composition of workload varied significantly by team role. Measuring learner workload during simulated resuscitations allows improved processes and choreography to optimise workload distribution.

Pediatric Simulation-Based Prehospital Training Course in Botswana.

Audience: This simulation-based training focuses on the most common and high risk pediatric prehospital scenarios in low- and middle-income countries (LMIC). The curriculum was developed based on a needs assessment to train Ministry of Health and Wellness (MOHW) prehospital providers in Botswana specifically for pediatric resuscitation and could be used for emergency medical services (EMS) providers in other LMIC. After participating in this curriculum, providers should enhance their assessment and interventions in acutely ill pediatric prehospital patients. Length of Curriculum: The entire course was designed to be presented over two days with 6-8 hours of instruction each day. Introduction: In recent years, prehospital medicine has shown continued growth in LMICs, specifically in Sub-Saharan Africa. As these programs develop focused training for the pediatric population, equipping the workforce with pediatric resuscitation skills is essential. A few years after its inception, the Botswana MOHW identified deficiencies in their current training program and sought external expertise and educational training. We partnered with the MOHW to create and implement a novel, prehospital simulation curriculum to teach pediatric resuscitation to prehospital providers. Our aim was to create a curriculum based on the needs of the community that could also be implemented in other similar resource-limited settings. This course included didactic sessions, five simulation scenarios using low fidelity mannequins and three pediatric-focused skill sessions. This program was found to be effective based on statistically significant improvement in written and simulation post-test scores. Educational Goals: The objective of this educational project was to design, implement, and evaluate a curriculum relevant to an EMS system based in a LMIC, so that it could be a basis for curricula for use in similar contexts. The educational goal is to improve prehospital providers performance in common pediatric resuscitations. Educational Methods: The educational methods used in this curriculum included simulation using rapid cycle deliberate practice (RCDP), didactic lectures, and hands on skills training for common pediatric scenarios. Outcomes were measured by comparing performance on written and simulation-based pre-and post-tests. Research Methods: Participants completed written and simulation-based pre- and post-tests covering the concepts taught in the curriculum. Continuous variables (written and simulation test scores) were compared between two dependent groups (pre- and post-trainings) using paired t-tests. Results: Mean written test scores increased by 11%, from 75% to 86% (p<0.0001), while mean simulated test scores increased by 22% (from 56% to 78 % (p<0.0001). Discussion: The curriculum we developed focused on high-yield pediatric skills based on the needs of the Botswana MOHW EMS program. We believe simulation training was an excellent and effective method for this type of training. We specifically designed RCDP scenarios for the training, due to the limited experience of the prehospital providers at that time. RCDP offers ample opportunities for feedback with immediate practice and improvement. Trainees demonstrated retention of knowledge and improved performance in simulation-based testing. The overall satisfaction level of the trainees was high and suggests additional training would be beneficial and desired. Additionally, as the results of our needs assessment mirrored common chief complaints in other LMIC countries in Sub-Saharan Africa1,2 we feel that this curriculum can be utilized and adopted with minor modifications in other LMIC settings, particularly where EMS programs are developing and in circumstances where few EMS providers have had extensive field experience. Topics: Respiratory distress, asthma, dehydration, hypovolemic shock, hypoglycemia, seizure, toxic ingestion, newborn resuscitation, precipitous delivery, traumatic injury, EMS, Botswana, global health, collaboration, rapid cycle deliberate practice (RCDP), medical simulation.

Educational impact of a pilot paediatric simulation-based training course in Botswana.

Background: As emergency medical services (EMS) systems develop globally in resource-limited settings, equipping providers with paediatric training is essential. Low-fidelity simulation-based training is an effective modality for training healthcare workers, though limited data exist on the impact of such training programmes. The objective of this study was to evaluate the paediatric portion of a simulation-based curriculum for prehospital providers in Botswana. Methods: This was a prospective cohort study of EMS providers from more populated regions of Botswana, who attended a 2-day training that included didactic lectures, hands-on skills stations and low-fidelity simulation training. We collected data on participant self-efficacy with paediatric knowledge and skills and performance on both written and simulation-based tests. Self-efficacy and test data were analysed, and qualitative course feedback was summarised. Results: Thirty-one EMS providers participated in the training. Median self-efficacy levels increased for 13/15 (87%) variables queried. The most notable improvements were observed in airway management, newborn resuscitation and weight estimation. Mean written test scores increased by 10.6%, while mean simulation test scores increased by 21.5% (p<0.0001). One hundred per cent of the participants rated the course as extremely useful or very useful. Discussion/Conclusion: We have demonstrated that a low-fidelity simulation-based training course based on a rigorous needs assessment may enhance short-term paediatric knowledge and skills for providers in a developing EMS system in a limited-resource setting. Future studies should focus on studying larger groups of learners in similar settings, especially with respect to the impact of educational programmes like these on real-world patient outcomes.

Evaluating a Novel Simulation Course for Prehospital Provider Resuscitation Training in Botswana.

INTRODUCTION: In 2012, Botswana embarked on an organized public approach to prehospital medicine. One goal of the Ministry of Health (MOH) was to improve provider education regarding patient stabilization and resuscitation. Simulation-based instruction is an effective educational strategy particularly for high-risk, low-frequency events. In collaboration with partners in the United States, the team created a short, simulation-based course to teach and update prehospital providers on common field responses in this resource-limited setting. The objective of this study was to evaluate an educational program for Botswanan prehospital providers via written and simulation-based examinations. METHODS: We developed a two-day course based on a formal needs assessment and MOH leadership input. The subject matter of the simulation scenarios represented common calls to the prehospital system in Botswana. Didactic lectures and facilitated skills training were conducted by U.S. practitioners who also served as instructors for a rapid-cycle, deliberate practice simulation education model and simulation-based testing scenarios. Three courses, held in three cities in Botswana, were offered to off-duty MOH prehospital providers, and the participants were evaluated using written multiple-choice tests, videotaped traditional simulation scenarios, and self-efficacy surveys. RESULTS: Collectively, 31 prehospital providers participated in the three courses. The mean scores on the written pretest were 67% (standard deviation [SD], 10) and 85% (SD, 7) on the post-test (p < 0.001). The mean scores for the simulation were 42% (SD, 14.2) on the pretest and 75% (SD, 11.3) on the post-test (p < 0.001). Moreover, the intraclass correlation coefficient scores between reviewers were highly correlated at 0.64 for single measures and 0.78 for average measures (p < 0.001 for both). Twenty-one participants (68%) considered the course "extremely useful." CONCLUSION: Botswanan prehospital providers who participated in this course significantly improved in both written and simulation-based performance testing. General feedback from the participants indicated that the simulation scenarios were the most useful and enjoyable aspects of the course. These results suggest that this curriculum can be a useful educational tool for teaching and reinforcing prehospital care concepts in Botswana and may be adapted for use in other resource-limited settings.

Rapid cycle deliberate practice vs. traditional simulation in a resource-limited setting.

BACKGROUND: We sought to develop a low-fidelity simulation-based curriculum for pediatric residents in Rwanda utilizing either rapid cycle deliberate practice (RCDP) or traditional debriefing, and to determine whether RCDP leads to greater improvement in simulation-based performance and in resident confidence compared with traditional debriefing. METHODS: Pediatric residents at the Centre Hospitalier Universitaire de Kigali (CHUK) were randomly assigned to RCDP or traditional simulation and completed a 6 month-long simulation-based curriculum designed to improve pediatric resuscitation skills. Pre- and post- performance was assessed using a modified version of the Simulation Team Assessment Tool (STAT). Each video-taped simulation was reviewed by two investigators and inter-rater reliability was assessed. Self-confidence in resuscitation, pre- and post-simulation, was assessed by Likert scale survey. Analyses were conducted using parametric and non-parametric testing, ANCOVA and intra-class correlation coefficients (ICC). RESULTS: There was a 21% increase in pre- to post-test performance in both groups (p < 0.001), but no difference between groups (mean difference - 0.003%; p 0.94). Inter-rater reliability was exceptional with both pre and post ICCs ≥0.95 (p < 0.001). Overall, self-confidence scores improved from pre to post (24.0 vs. 30.0 respectively, p < 0.001), however, the there was no difference between the RCDP and traditional groups. CONCLUSIONS: Completion of a six-month low-fidelity simulation-based curriculum for pediatric residents in Rwanda led to statistically significant improvement in performance on a simulated resuscitation. RCDP and traditional low-fidelity simulation-based instruction may both be valuable tools to improve resuscitation skills in pediatric residents in resource-limited settings.

Needs Assessment for Simulation Training for Prehospital Providers in Botswana.

BACKGROUND: In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques. OBJECTIVE: The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum. METHODS: Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs. RESULTS: Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data. CONCLUSIONS: Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries. GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB. Needs assessment for simulation training for prehospital providers in Botswana. Prehosp Disaster Med. 2018;33(6):621-626.

Building Sustainable Partnerships to Strengthen Pediatric Capacity at a Government Hospital in Malawi.

INTRODUCTION: To achieve sustained reductions in child mortality in low- and middle-income countries, increased local capacity is necessary. One approach to capacity building is support offered via partnerships with institutions in high-income countries. However, lack of cooperation between institutions can create barriers to successful implementation of programs and may inadvertently weaken the health system they are striving to improve. A coordinated approach is necessary. BACKGROUND: Three U.S.-based institutions have separately supported various aspects of pediatric care at Kamuzu Central Hospital (KCH), the main government referral hospital in the central region of Malawi, for several years. Within each institution's experience, common themes were recognized, which required attention in order to sustain improvements in care. Each recognized that support of clinical care is a necessary cornerstone before initiating educational or training efforts. In particular, the support of emergency and acute care is paramount in order to decrease in-hospital mortality. Through the combined efforts of Malawian partners and the US-based institutions, the pediatric mortality rate has decreased from >10 to <4% since 2011, yet critical gaps remain. To achieve further improvements, representatives with expertise in pediatric emergency medicine (PEM) from each US-based institution hypothesized that coordinated efforts would be most effective, decrease duplication, improve communication, and ensure that investments in education and training are aligned with local priorities. CALL TO ACTION: Together with local stakeholders, the three US-based partners created a multi-institutional partnership, Pediatric Alliance for Child Health Improvement in Malawi at Kamuzu Central Hospital and Environs (PACHIMAKE). Representatives from each institution gathered in Malawi late 2016 and sought input and support from local partners at all levels to prioritize interventions, which could be collectively undertaken by this consortium. Long- and short-term goals were identified and approved by local partners and will be implemented through a phased approach. CONCLUSION: The development of a novel partnership between relevant stakeholders in Malawi and US-based partners with expertise in PEM should help to further decrease pediatric mortality through the coordinated provision of acute care expertise and training as well as investment in the development of educational, research, and clinical efforts in PEM at KCH.