A Modified Delphi Study for Curricular Content of Simulation-Based Medical Education for Pediatric Residency Programs.

OBJECTIVE: We sought to establish core knowledge topics and skills that are important to teach pediatric residents using simulation-based medical education (SBME). METHODS: We conducted a modified Delphi process with experts in pediatric SBME. Content items were adapted from the American Board of Pediatrics certifying exam content and curricular components from pediatric entrustable professional activities (EPAs). In round 1, participants rated 158 items using a four-point Likert scale of importance to teach through simulation in pediatric residency. A priori, we defined consensus for item inclusion as ≥70% rated the item as extremely important and exclusion as ≥70% rated the item not important. Criteria for stopping the process included reaching consensus to include and/or exclude all items, with a maximum of three rounds. RESULTS: A total of 59 participants, representing 46 programs and 25 states participated in the study. Response rates for the three rounds were 92%, 86% and 90%, respectively. The final list includes 112 curricular content items deemed by our experts as important to teach through simulation in pediatric residency. Seventeen procedures were included. Nine of the seventeen EPAs had at least one content item that experts considered important to teach through simulation as compared to other modalities. CONCLUSIONS: Using consensus methodology, we identified the curricular items important to teach pediatric residents using SBME. Next steps are to design a simulation curriculum to encompass this content.

Can hospital adult code-teams and individual members perform high-quality CPR? A multicenter simulation-based study incorporating an educational intervention with CPR feedback.

AIMS: A multicenter simulation-based research study to assess the ability of interprofessional code-teams and individual members to perform high-quality CPR (HQ-CPR) at baseline and following an educational intervention with a CPR feedback device. METHODS: Five centers recruited ten interprofessional teams of AHA-certified adult code-team members with a goal of 200 participants. Baseline testing of chest compression (CC) quality was measured for all individuals. Teams participated in a baseline simulated cardiac arrest (SCA) where CC quality, chest compression fraction (CCF), and peri-shock pauses were recorded. Teams participated in a standardized HQ-CPR and abbreviated TeamSTEPPS® didactic, then engaged in deliberate practice with a CPR feedback device. Individuals were assessed to determine if they could achieve ≥80% combined rate and depth within 2020 AHA guidelines. Teams completed a second SCA and CPR metrics were recorded. Feedback was disabled for assessments except at one site where real-time CPR feedback was the institutional standard. Linear regression models were used to test for site effect and paired t-tests to evaluate significant score changes. Logistic univariate regression models were used to explore characteristics associated with the individual achieving competency. RESULTS: Data from 184 individuals and 45 teams were analyzed. Baseline HQ-CPR mean score across all sites was 18.5% for individuals and 13.8% for teams. Post-intervention HQ-CPR mean score was 59.8% for individuals and 37.0% for teams. There was a statistically significant improvement in HQ-CPR mean scores of 41.3% (36.1, 46.5) for individuals and 23.2% (17.1, 29.3) for teams (p < 0.0001). CCF increased at 3 out of 5 sites and there was a mean 5-s reduction in peri-shock pauses (p < 0.0001). Characteristics with a statistically significant association were height (p = 0.01) and number of times performed CPR (p = 0.01). CONCLUSION: Code-teams and individuals struggle to perform HQ-CPR but show improvement after deliberate practice with feedback as part of an educational intervention. Only one site that incorporated real-time CPR feedback devices routinely achieved ≥80% HQ-CPR.

Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback.

OBJECTIVES: Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time. METHODS: We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation. RESULTS: There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05). CONCLUSIONS: There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.

Pediatric Airway Assessment Tool (PAAT): A Rating Tool to Assess Resident Proficiency in Simulated Pediatric Airway Skills Performance.

Introduction: The Accreditation Council for Graduate Medical Education has identified the need for assessment of core skills for pediatric and emergency medicine residents, which includes pediatric airway management. Although there are standard courses for pediatric airway management, there is no validated tool to assess basic and advanced pediatric airway skills performance. Our objective was to develop a simulation-based tool for the formative assessment of resident pediatric airway skills performance that was concise, yet comprehensive, and to evaluate the evidence supporting the argument for the tool's validity. Methods: We developed a pediatric airway assessment tool (PAAT) to assess six major domains of pediatric airway skills performance: basic airway maneuvers, airway adjuncts, bag-valve mask ventilation, advanced airway equipment preparation, direct laryngoscopy, and video laryngoscopy. This tool consisted of a 72-item pediatric airway skills assessment checklist to be used in simulation. We enrolled 12 subjects at four different training levels to participate. Assessment scores were rated by two independent expert raters. Results: The interrater agreement was high, ranging from 0.92 (adult bagging rate) to 1 (basic airway maneuvers). There was a significant trend of increasing scores with increased training level. Discussion: The PAAT demonstrated excellent interrater reliability and provided evidence of the construct's validity. Although further validation of this assessment tool is needed, these results suggest that the PAAT may eventually be useful for assessment of resident proficiency in pediatric airway skills performance.

Impact of a CPR feedback device on healthcare provider workload during simulated cardiac arrest.

OBJECTIVE: We aimed to describe the differences in workload between team leaders and CPR providers during a simulated pediatric cardiac arrest, to evaluate the impact of a CPR feedback device on provider workload, and to describe the association between provider workload and the quality of CPR. METHODS: We conducted secondary analysis of data from a randomized trial comparing CPR quality in teams with and without use of a real-time visual CPR feedback device [1]. Healthcare providers (team leaders and CPR providers) completed the NASA Task Load Index survey after participating in a simulated cardiac arrest scenario. The effect of provider roles and real-time feedback on workload were compared with independent t-tests. RESULTS: Team leaders reported higher levels of mental demand, temporal demand, performance-related workload and frustration, while CPR providers reported comparatively higher physical workload. CPR providers reported significantly higher average workload (control 58.5 vs. feedback 62.3; p = 0.035) with real-time feedback provided compared to the group without feedback. Providers with high workloads (average score >60) had an increased percentage of time with guideline-compliant CPR depth versus those with low workloads (average score <60) (p = 0.034). CONCLUSIONS: Healthcare providers reported high workloads during a simulated pediatric cardiac arrest. Physical and mental workloads differed based on provider role. CPR providers using a CPR feedback device reported increased average workloads. The quality of CPR improved with higher reported physical workloads.

Electronic Medical Record in the ED: A Cross-Sectional Survey of Resuscitation Documentation Practices and Perceptions Among Emergency Department Clinicians.

OBJECTIVES: The aims of this study were to describe current practices in nursing documentation of trauma and medical resuscitations across emergency departments (EDs) and explore physicians' and nurses' perceptions of electronic medical record (EMR) use for nursing documentation of resuscitations. METHODS: An anonymous Web-based survey was developed and distributed to a convenience sample of ED physicians and nurses in the United States. RESULTS: Of 438 respondents, 154 were nurses; 97.2% of respondents reported that their EDs use EMR generally. Of those, 51.2% use EMR to document resuscitations. When describing documentation processes, 19% (95% confidence interval [CI], 15%-23%) reported direct documentation on EMR, 18% (95% CI, 14%-21%) reported documenting on paper before transferring to EMR, and 22% (95% CI, 18%-26%) reported simultaneously documenting on EMR and paper. Thirty-seven percent of respondents reported that the "documentor" frequently performs other tasks during resuscitations. Few nurses (39.6%) and physicians (26.4%) perceived EMR as more efficient than paper. Nurses (66.2%) and physicians (51.8%) perceived paper as more complete than EMR. Few nurses (31.6%) and physicians (25.6%) agreed that paper would facilitate continuity of care better than EMR. No associations between nurses' perceptions of EMR, professional experience, or technology use were found. CONCLUSIONS: Although EMR adoption was common among respondents, only half reported using EMR to document resuscitations. Even fewer reported documenting directly on EMR, whereas a significant proportion reported processes that may be inefficient, redundant, or prone to errors. Respondents endorsed mostly negative perceptions of EMR. Our findings suggest that there may be factors inherent to resuscitations and the existing EMR interfaces that render documenting resuscitations on EMR uniquely challenging.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills.

OBJECTIVE: Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT). METHODS: Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK. RESULTS: The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073). CONCLUSION: This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

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.

Comparing the Accuracy of Three Pediatric Disaster Triage Strategies: A Simulation-Based Investigation.

BACKGROUND: It is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes. METHODS: We conducted a cross-sectional analysis on a sample of emergency medical services providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients' expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased). RESULTS: There were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (P<0.001; OR [odds ratio]: 2.03; interquartile range [IQR]: 1.30, 3.17) or CDM (P=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (P<0.001; OR: 3.22; IQR: 1.78,5.88) and CDM (P<0.001; OR: 2.86; IQR: 1.53,5.26) for YELLOW patients. Furthermore, JumpSTART outperformed CDM for BLACK patients (P=0.01; OR: 5.55; IQR: 1.47, 20.0). CONCLUSION: Our simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM.

Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions.

AIM: The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest. METHODS: We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate. RESULTS: We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001). CONCLUSION: The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

In situ medical simulation investigation of emergency department procedural sedation with randomized trial of experimental bedside clinical process guidance intervention.

INTRODUCTION: Patient safety during emergency department procedural sedation (EDPS) can be difficult to study. Investigators sought to delineate and experimentally assess EDPS performance and safety practices of senior-level emergency medicine residents through in situ simulation. METHODS: Study sessions used 2 pilot-tested EDPS scenarios with critical action checklists, institutional forms, embedded probes, and situational awareness questionnaires. An experimental informatics system was separately developed for bedside EDPS process guidance. Postgraduate year 3 and 4 subjects completed both scenarios in randomized order; only experimental subjects were provided with the experimental system during second scenarios. RESULTS: Twenty-four residents were recruited into a control group (n = 12; 6.2 ± 7.4 live EDPS experience) and experimental group (n = 12; 11.3 ± 8.2 live EDPS experience [P = 0.10]). Critical actions for EDPS medication selection, induction, and adverse event recognition with resuscitation were correctly performed by most subjects. Presedation evaluations, sedation rescue preparation, equipment checks, time-outs, and documentation were frequently missed. Time-outs and postsedation assessments increased during second scenarios in the experimental group. Emergency department procedural sedation safety probe detection did not change across scenarios in either group. Situational awareness scores were 51% ± 7% for control group and 58% ± 12% for experimental group. Subjects using the experimental system completed more time-outs and scored higher Simulation EDPS Safety Composite Scores, although without comprehensive improvements in EDPS practice or safety. CONCLUSIONS: Study simulations delineated EDPS and assessed safety behaviors in senior emergency medicine residents, who exhibited the requisite medical knowledge base and procedural skill set but lacked some nontechnical skills that pertain to emergency department microsystem functions and patient safety. The experimental system exhibited limited impact only on in-simulation time-out compliance.

Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role.

AIM: Many healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions. METHODS: We conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm. RESULTS: Participants overestimated achieving adequate chest compression depth (mean difference range: 16.1-60.6%) and rate (range: 0.2-51%), and underestimated chest compression fraction (0.2-2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p<0.001). Accurate estimation of CPR quality was poor for chest compression depth (0-13%), rate (5-46%) and chest compression fraction (60-63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p=0.043) when using real-time feedback. CONCLUSION: Healthcare providers' visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.

Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial.

IMPORTANCE: The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines. OBJECTIVE: To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA. DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams). INTERVENTIONS: Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA. MAIN OUTCOMES AND MEASURES: The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA. RESULTS: The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation. CONCLUSIONS AND RELEVANCE: The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02075450.

Development of a survey of teamwork and task load among medical providers: a measure of provider perceptions of teamwork when caring for critical pediatric patients.

INTRODUCTION: Teamwork training focuses on improving patient outcomes through better communication. Scales exist to assess providers' perceptions of teamwork; however, they are not designed for use immediately after the care of critically ill patients. OBJECTIVES: This study aimed to develop a survey to quantify providers' perceptions of teamwork and task load during critical care resuscitations in a PED and to use the tool to compare physician and nonphysician ratings of resuscitations. METHODS: Survey items were adapted from validated tools. The resulting survey contained 15 Likert scale items completed by providers immediately after resuscitations. An exploratory factor analysis was conducted. Mixed models, accounting for clustering of providers within resuscitations, tested for systematic differences in responses between physicians and nonphysicians and explored how well the factor scores predicted the overall "smoothness" of the resuscitation. RESULTS: Six hundred fifty-four surveys from 169 resuscitations were conducted. The exploratory factor analysis identified 2 factors with 13 items explaining 47% of the overall variance of "teamwork and communication" (Cronbach α = 0.80) and "task load" (Cronbach α = 0.77). There were no differences in factors predicting smoothness between physicians and nonphysicians (P = 0.27). Both were significant positive predictors of the outcome "the resuscitation went smoothly." CONCLUSIONS: The Survey of Teamwork and Task Load among Medical Providers was developed to evaluate providers' perceptions of teamwork immediately after care of critically ill patients in a pediatric emergency department. Items reflect 2 constructs, with good internal consistency. Responses did not vary by professional training, suggesting that it is useful for all providers. Both factors predicted the overall smoothness. Each was useful in predicting the perception that the resuscitation went smoothly.

'Not just little adults' - a pediatric trauma primer.

This article describes pediatric trauma care and specifically how a pediatric trauma center, like Hasbro Children's Hospital, provides specialized care to this patient population. The authors review unique aspects of pediatric trauma patients broken down into anatomy and physiology, including Airway and Respiratory, Cardiovascular Response to Hemorrhage, Spine Injuries, Traumatic Brain Injuries, Thoracic Injuries and Blunt Abdominal Trauma. They review certain current recommendations for evaluation and management of these pediatric patients. The authors also briefly review the topic of Child Abuse/Non-accidental Trauma in pediatric patients. Although Pediatric Trauma is a very broad topic, the goal of this article is to act as a primer and describe certain characteristics and management recommendations unique to the pediatric trauma patient.

Creation and Delphi-method refinement of pediatric disaster triage simulations.

OBJECTIVE: There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. METHODS: We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. RESULTS: After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. CONCLUSIONS: The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation.

OBJECTIVES: The objective was to determine if a medical simulation-based neonatal resuscitation educational intervention is a more effective teaching method than the current emergency medicine (EM) curriculum at one 4-year EM residency program. METHODS: A prospective, randomized study of second-, third-, and fourth-year EM residents was performed. Of 36 potential subjects, 27 residents were enrolled. Each resident was assessed at baseline and after the intervention using 1) a questionnaire to evaluate confidence in leading adult, pediatric, and neonatal resuscitation and prior neonatal resuscitation experience and 2) a neonatal resuscitation simulation scenario in which each participant was the code leader to evaluate knowledge and skills. Assessments were digitally recorded and reviewed independently by two Neonatal Resuscitation Program (NRP) instructors using a validated neonatal resuscitation scoring tool. Controls (15 participants) received the current EM curriculum. The intervention group (12 participants) experienced an educational session, which incorporated didactics, skills station, and medical simulation about neonatal resuscitation. Outcomes measured included changes in overall neonatal resuscitation score, number of critical actions, time to initial steps of neonatal resuscitation, and changes in confidence level leading neonatal resuscitation. RESULTS: Baseline neonatal resuscitation scores were similar for the control and intervention groups. At the final assessment, the intervention group's neonatal resuscitation score improved (p = 0.016) and the control group's score did not. The intervention group performed 2.31 more critical actions overall and the time to achieve warming (p = 0.0002), drying (p < 0.0001), tactile stimulation (p = 0.002), and placing a hat on the patient (p <0.0001) were also improved compared to controls. At the baseline assessment, 80% of the control group and 75% of the intervention group reported being "not at all confident" in leading neonatal resuscitation. At the final assessment, the proportion of residents who were "not at all confident" leading neonatal resuscitation decreased to 35% in the intervention group compared to 67% of the control group. The majority of the intervention group (65%) reported an increased level of confidence in leading neonatal resuscitation. CONCLUSIONS: Medical simulation can be an effective tool to assess the knowledge and skills of EM residents in neonatal resuscitation. Our simulation-based educational intervention significantly improved EM residents' knowledge and performance of the critical initial steps in neonatal resuscitation. A medical simulation-based educational intervention may be used to improve EM residents' knowledge and performance with neonatal resuscitation.

Pilot-phase findings from high-fidelity In Situ medical simulation investigation of emergency department procedural sedation.

INTRODUCTION: Emergency department procedural sedation (EDPS) is becoming widespread. Simulation may enhance patient safety through evidence-based training, effective assessment, and research of EDPS operators in pertinent knowledge, skills, processes, and teamwork. METHODS: Investigators developed a 2-scenario in situ simulation-based methodology and research tool kit for objective examination of EDPS practice. The emphasis was on protocol-driven presedation preparation, intrasedation vigilance and readiness for adverse events, and postsedation reassessment. Pilot sessions were conducted to test the methodology at an academic 719-bed hospital, with Institutional Review Board approval. RESULTS: Five interns and 5 attending emergency physicians completed pilot sessions resulting in protocol revisions to optimize simulation consistency, research tool sets, data acquisition, and operational conditions. Pilot data sets demonstrated interscenario consistency and intersubject reproducibility for timing, progression, and duration of critical EDPS events; high levels of perceived realism and relevance; and utility and suggested validity of the study methodology as an EDPS research mechanism. Small sample sizes limited the study methodology's ability to distinguish between the subject groups' clinical performances (critical action completion, probe detection, and situational awareness) except with composite scoring of presedation and postsedation assessments. Key EDPS preparation, adverse event management, and reassessment actions were selected to derive a Simulation EDPS Safety Composite Score that differentiated inexperienced [4.60 ± 0.8 on a 10-point score (n = 3)] and experienced EDPS operators [8.95 ± 1.03 (n = 5); P = 0.0007]. CONCLUSIONS: In situ simulation is a useful and relevant means to investigate EDPS patient safety. Pilot sessions have cleared the way for further experimental safety intervention research and development with the simulation-based methodology.

Design, implementation, and psychometric analysis of a scoring instrument for simulated pediatric resuscitation: a report from the EXPRESS pediatric investigators.

INTRODUCTION: Robustly tested instruments for quantifying clinical performance during pediatric resuscitation are lacking. Examining Pediatric Resuscitation Education through Simulation and Scripting Collaborative was established to conduct multicenter trials of simulation education in pediatric resuscitation, evaluating performance with multiple instruments, one of which is the Clinical Performance Tool (CPT). We hypothesize that the CPT will measure clinical performance during simulated pediatric resuscitation in a reliable and valid manner. METHODS: Using a pediatric resuscitation scenario as a basis, a scoring system was designed based on Pediatric Advanced Life Support algorithms comprising 21 tasks. Each task was scored as follows: task not performed (0 points); task performed partially, incorrectly, or late (1 point); and task performed completely, correctly, and within the recommended time frame (2 points). Study teams at 14 children's hospitals went through the scenario twice (PRE and POST) with an interposed 20-minute debriefing. Both scenarios for each of eight study teams were scored by multiple raters. A generalizability study, based on the PRE scores, was conducted to investigate the sources of measurement error in the CPT total scores. Inter-rater reliability was estimated based on the variance components. Validity was assessed by repeated measures analysis of variance comparing PRE and POST scores. RESULTS: Sixteen resuscitation scenarios were reviewed and scored by seven raters. Inter-rater reliability for the overall CPT score was 0.63. POST scores were found to be significantly improved compared with PRE scores when controlled for within-subject covariance (F1,15 = 4.64, P < 0.05). The variance component ascribable to rater was 2.4%. CONCLUSIONS: Reliable and valid measures of performance in simulated pediatric resuscitation can be obtained from the CPT. Future studies should examine the applicability of trichotomous scoring instruments to other clinical scenarios, as well as performance during actual resuscitations.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation.

INTRODUCTION: High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS: Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS: 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION: On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.