The Chief Residency in U.S. and Canadian Graduate Medical Education: A Scoping Review.

PHENOMENON: Despite the nearly universal presence of chief residents within U.S. and Canadian residency programs and their critical importance in graduate medical education, to our knowledge, a comprehensive synthesis of publications about chief residency does not exist. An understanding of the current state of the literature can be helpful to program leadership to make evidence-based improvements to the chief residency and for medical education researchers to recognize and fill gaps in the literature. APPROACH: We performed a scoping review of the literature about chief residency. We searched OVID Medline, PsycINFO, ERIC, and Web of Science databases through January 2023 for publications about chief residency. We included publications addressing chief residency in ACGME specialties in the U.S. and Canada and only those using the term "chief resident" to refer to additional responsibilities beyond the typical residency training. We excluded publications using chief residents as a convenience sample. We performed a topic analysis to identify common topics among studies. FINDINGS: We identified 2,064 publications. We performed title and abstract screening on 1,306 and full text review on 208, resulting in 146 included studies. Roughly half of the publications represented the specialties of Internal Medicine (n = 37, 25.3%) and Psychiatry (n = 30, 20.5%). Topic analysis revealed six major topics: (1) selection of chief residents (2) qualities of chief residents (3) training of chief residents (4) roles of chief residents (5) benefits/challenges of chief residency (6) outcomes after chief residency. INSIGHTS: After reviewing our topic analysis, we identified three key areas warranting increased attention with opportunity for future study: (1) addressing equity and bias in chief resident selection (2) establishment of structured expectations, mentorship, and training of chief residents and (3) increased attention to chief resident experience and career development, including potential downsides of the role.

Effect of repeat refresher courses on neonatal resuscitation skill decay: an experimental comparative study of in-person and video-based simulation training.

Neonatal deaths are a major contributor to global under-5-year-old mortality. Training birth attendants can improve perinatal outcomes, but skills may fade over time. In this pilot study, we assessed skill decay of nursing students after remote video versus in-person resuscitation training in a low-resource setting. Filipino nursing students (n = 49) underwent traditional, in-person simulation-based Helping Babies Breathe (HBB) training in Mindanao, Philippines. Participants were then assigned to receive refresher training at 2-month intervals either in-person or via tele-simulation beginning at 2 months, 4 months, or 6 months after initial training. A knowledge examination and practical examination, also known as objective structured clinical examination B in the HBB curriculum, were administered before retraining to assess knowledge and skill retention at time of scheduled follow-up. Time to initiation of bag-mask ventilation (BMV) in seconds during simulated birth asphyxia was the primary outcome. Skill decay was evident at first follow-up, with average time to BMV increasing from 56.9 (range 15-87) s at initial post-training to 83.8 (range 32-128) s at 2 months and 90.2 (range 51-180) s at 4 months. At second follow-up of the 2-month group, students showed improved pre-training time to BMV (average 70.4; range 46-97 s). No statistical difference was observed between in-person and video-trained students in time to BMV. Because of COVID-19 restrictions, the 6-month follow-up was not completed. We conclude that remote video refresher training is a reasonable alternative to traditional in-person HBB training. Our study also suggests that refreshers may be needed more frequently than every 2 months to mitigate skill decay. Additional studies are necessary to assess the longitudinal impact of tele-simulation on clinical outcomes.

Resident Perceptions of Continuity Clinic Patient Metrics Differ From EHR Data: Pilot Use of Population Health Dashboards.

BACKGROUND AND OBJECTIVES: Population health management (PHM) dashboards using electronic health record (EHR) data can teach trainees about the population they serve while also delivering data on their clinical practice. Yet, few studies have demonstrated their use. In this pilot study, we assessed baseline resident perceptions of population health metrics for continuity clinic panels by comparing resident estimates with EHR-reported values delivered by individualized PHM dashboards. METHODS: A descriptive, comparative study was conducted at a primary continuity clinic site for pediatric residents in January 2018. Residents were surveyed about population health metrics for their patient panels, including demographics, utilization, and medical diagnoses. We compared resident estimates to corresponding EHR-reported values using 2-tailed paired t tests. RESULTS: A total of 42 out of 55 eligible residents (76%) completed the survey. Compared with EHR-reported values, residents estimated higher percentages of emergency department utilization (22.1% vs 10.3%, P < .01) and morbidity, including medical complexity (15.6% vs 5.9%, P < .01), overweight (38.1% vs 11.7%, P < .01), obesity (20.5% vs 15.8%, P = .02), and asthma (34.6% vs 21.4%, P < .01). CONCLUSIONS: In this pilot study of PHM dashboards, resident perceptions of continuity clinic population health metrics did not align with EHR data. Estimates were higher for measures of utilization and morbidity. PHM dashboards may help trainees better understand their patient populations and serve as a consistent source of objective practice data. However, further research and investment is needed to evaluate dashboard implementation and impact on trainee and patient outcomes.

Midwives' Perspectives on Family Planning With Pregnant and Postpartum Women in the Philippines' Mindanao Region: A Qualitative Study.

Background This study sought to identify factors significantly impacting access to and utilization of modern contraceptive methods among Filipinas from the perspective of midwives who are caring for women during pregnancy and the postpartum period. Methods In-depth, semi-structured interviews were conducted with 10 midwives working at three birthing clinics within the Mindanao region of the Philippines. Data were coded and analyzed for major themes using a grounded theory approach. Results Logistics of obtaining the desired contraceptive method, superstitions associated with family planning (FP) methods, opinions of community leaders and partners, and education regarding fertility and birth spacing benefits are significant factors impacting Filipina family planning use. Religion and midwives' preferences are not significant factors. Conclusions Cultural and social factors play a large role in family planning decisions. There is a need for enhanced education, beginning in schools, regarding the fertility cycle, birth spacing benefits, and the importance of individual family planning. Filipino public health infrastructure operating consistently is a key factor for women to reliably access contraception.

Implementation and evaluation of a shock curriculum using simulation in Manila, Philippines: a prospective cohort study.

BACKGROUND: Shock causes significant morbidity and mortality in children living in resource-limited settings. Simulation has been successfully used as an educational tool for medical professionals internationally. We sought to improve comfort and knowledge regarding shock recognition and fluid management by implementing a pediatric shock curriculum using simulation as an assessment for trainees in Manila, Philippines. METHODS: We assessed a shock curriculum focused on patients with malnutrition in a prospective cohort study, using a written test and a videotaped simulation-based objective standardized clinical examination. Implementation occurred in March 2020 with 24 Filipino pediatric residents at a single institution in Manila. Outcomes included time to initiation of fluid resuscitation, improvement in confidence, knowledge on a written assessment, and performance in simulation. Results were compared pre- and post-intervention using Wilcoxon signed-rank test. RESULTS: The time to initiation of fluids did not change between the baseline simulation (median [interquartile range] = 71.5 seconds [52-116.5]) and the final simulation (68 seconds [52.5-89]; P = 0.42). Confidence in identifying shock and malnutrition, managing hypovolemic shock, managing septic shock, and placing intraosseous access all increased (P < 0.01) post-intervention. Written test scores showed no improvement, but performance in simulation, measured using a checklist, improved from a total score of 10 [8.5-11] to 15 [13-16] (P < 0.01). CONCLUSION: In our study of a simulation-based shock education program, we showed improvement in confidence and knowledge as measured by a resuscitation checklist. It is feasible to establish a successful simulation-based education program in a low-resource setting.

Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting.

Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.

Best Practices and Theoretical Foundations for Simulation Instruction Using Rapid-Cycle Deliberate Practice.

STATEMENT: Rapid-cycle deliberate practice (RCDP) is a learner-centered simulation instructional strategy that identifies performance gaps and targets feedback to improve individual or team deficiencies. Learners have multiple opportunities to practice observational, deductive, decision-making, psychomotor, and crisis resource management skills. As its implementation grows, simulationists need to have a shared mental model of RCDP to build high-quality RCDP-based initiatives. To compare and make general inferences from RCDP data, each training needs to follow a similar structure. This article seeks to describe the fundamentals of RCDP, including essential components and potential variants. We also summarize the current published evidence regarding RCDP's effectiveness. This article serves to create a shared understanding of RCDP, provide clear definitions and classifications for RCDP research, and provide options for future RCDP investigation.

Saving Lives and Improving the Quality of Pediatric Resuscitation Across the World: A 1-Day Research Accelerator Hosted by the International Network for Simulation-based Pediatric Innovation, Research, and Education and the International Pediatric Simulation Society.

STATEMENT: The International Network for Simulation-based Pediatric Innovation, Research, and Education co-hosted a novel research accelerator meeting with the International Pediatric Simulation Society in May of 2019 in Toronto. The purpose of the meeting was to bring together healthcare simulation scientists with resuscitation stakeholders to brainstorm strategies for accelerating progress in the science of saving pediatric lives from cardiac arrest. This was achieved by working in teams to draft targeted requests for proposals calling the research community to action investigating this topic. During the 1-day meeting, groups were divided into 6 teams lead by experts representing specific domains of simulation research. Teams developed a pitch and presented a sample request for proposals to a panel of expert judges, making a case for why their domain was the most important to create a funding opportunity. The winner of the competition had their specific request for proposal turned into an actual funding opportunity, supported by philanthropy that was subsequently disseminated through International Network for Simulation-based Pediatric Innovation, Research, and Education as a competitive award. An inspired donor supported an award for the second-place proposal as well, evidence of early research acceleration catalyzed from this conference. This article is a summary of the meeting rationale, format, and a description of the requests for proposals that emerged from the meeting. Our goal is to inspire other stakeholders to use this document that leverages simulation and resuscitation science expertise, as the framework to create their own funding opportunities, further accelerating pediatric resuscitation research, ultimately saving the lives of more children worldwide.

Rapid Cycle Deliberate Practice (RCDP) as a Method to Improve Airway Management Skills - A Randomized Controlled Simulation Study.

BACKGROUND: Paediatric intubations are a relatively rare but critical procedure that requires adequate practice to achieve skillful performance. Simulation is a method to teach intubation skills in a safe environment. Rapid Cycle Deliberate Practice (RCDP), as a method of simulation debriefing, has been shown to improve pediatric resident resuscitation skills. It has not been demonstrated if RCDP can be effectively used in procedural skills training. The objective of this study was to determine if RCDP with feedback in real-time, as well as an opportunity to repeat the action, is superior to a simulation where no feedback is provided during the simulation and is instead provided after the simulation. MATERIALS AND METHODS: This was a randomized controlled single-blinded study. All participants were videotaped during a simulated pre-assessment intubation, then received either the intervention (RCDP) or the control teaching (feedback after the simulation), followed by a post-assessment intubation. These videos were scored by two independent raters on an intubation checklist. The primary outcome was the change in score. The secondary outcome was intubation success. RESULTS: Thirty-five students met the inclusion criteria. The RCDP group achieved a significantly higher score improvement in the preparation and post-procedure care categories. The overall score change in the RCDP group was significantly higher than in the control group, with a mean difference of -11.86 (CI -15.57 to -8.15, p<0.00001), but there was no significant improvement in intubation success. CONCLUSION: Our study suggests that RCDP is an effective method to teach the procedural skill of intubation with an emphasis on procedural choreography. RCDP could be an appropriate method for debriefing learners in procedural skills training in this population.

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs.

Introduction Difficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described. Materials and methods We used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents' experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results. Results These survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as "fair" or "good" (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters. Discussion We found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors. Conclusions Next steps include creating a "Difficult Encounters" communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

A Multi-Institutional Simulation Boot Camp for Pediatric Cardiac Critical Care Nurse Practitioners.

OBJECTIVES: Assess the effect of a simulation "boot camp" on the ability of pediatric nurse practitioners to identify and treat a low cardiac output state in postoperative patients with congenital heart disease. Additionally, assess the pediatric nurse practitioners' confidence and satisfaction with simulation training. DESIGN: Prospective pre/post interventional pilot study. SETTING: University simulation center. SUBJECTS: Thirty acute care pediatric nurse practitioners from 13 academic medical centers in North America. INTERVENTIONS: We conducted an expert opinion survey to guide curriculum development. The curriculum included didactic sessions, case studies, and high-fidelity simulation, based on high-complexity cases, congenital heart disease benchmark procedures, and a mix of lesion-specific postoperative complications. To cover multiple, high-complexity cases, we implemented Rapid Cycle Deliberate Practice method of teaching for selected simulation scenarios using an expert driven checklist. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed with a pre-/posttest format (maximum score, 100%). A paired-sample t test showed a statistically significant increase in the posttest scores (mean [SD], pre test, 36.8% [14.3%] vs post test, 56.0% [15.8%]; p < 0.001). Time to recognize and treat an acute deterioration was evaluated through the use of selected high-fidelity simulation. Median time improved overall "time to task" across these scenarios. There was a significant increase in the proportion of clinically time-sensitive tasks completed within 5 minutes (pre, 60% [30/50] vs post, 86% [43/50]; p = 0.003] Confidence and satisfaction were evaluated with a validated tool ("Student Satisfaction and Self-Confidence in Learning"). Using a five-point Likert scale, the participants reported a high level of satisfaction (4.7 ± 0.30) and performance confidence (4.8 ± 0.31) with the simulation experience. CONCLUSIONS: Although simulation boot camps have been used effectively for training physicians and educating critical care providers, this was a novel approach to educating pediatric nurse practitioners from multiple academic centers. The course improved overall knowledge, and the pediatric nurse practitioners reported satisfaction and confidence in the simulation experience.

Cognitive Aids Do Not Prompt Initiation of Cardiopulmonary Resuscitation in Simulated Pediatric Cardiopulmonary Arrests.

INTRODUCTION: Although American Heart Association guidelines exist for proper management of cardiopulmonary arrest (CPA), in-hospital cardiopulmonary resuscitation (CPR) may be of poor quality and is not performed in all indicated situations. Cognitive aids have been created to assist in rapid, accurate recall of guidelines for pediatric CPA management. METHODS: Pediatric residents participated in individual mock codes for two years. Using a high-fidelity simulator, each resident participated in a standardized scenario that required management of both pulseless ventricular tachycardia and pulseless electrical activity. The primary study objective was to calculate the proportion of residents (a) who were not performing CPR on a simulated "pulseless" patient when cognitive aid use was first initiated and (b) who subsequently initiated CPR after cognitive aid use. RESULTS: One hundred thirty-two (83.5%) of 158 pediatric residents participated, and of 125 videos available for review, 107 residents (85.6%) used a cognitive aid. Mean (SD) time to cognitive aid use was 106 (100) seconds after the mannequin became pulseless. Most common immediate actions prompted by cognitive aid use were the following: defibrillation, 43 (40%) of 107; and adrenaline (epinephrine) administration, 28 (26%) of 107. Most alarmingly, 58 (54%) of 107 were not performing CPR on the pulseless patient when cognitive aid use was initiated and only two (3.4%) of 58 were subsequently prompted to initiate chest compressions. DISCUSSION: Cognitive aids in use during this study did not prompt timely initiation of CPR, potentially contributing to delays and errors in CPA management. Failure of these aids to prompt CPR initiation represents a "missed opportunity" to enhance performance of this vital skill.

Design, Implementation, and Evaluation of a Simulation-Based Clinical Correlation Curriculum as an Adjunctive Pedagogy in an Anatomy Course.

PROBLEM: Because reported use of simulation in preclinical basic science courses is limited, the authors describe the design, implementation, and preliminary evaluation of a simulation-based clinical correlation curriculum in an anatomy course for first-year medical students at Perdana University Graduate School of Medicine (in collaboration with Johns Hopkins University School of Medicine). APPROACH: The simulation curriculum, with five weekly modules, was a component of a noncadaveric human anatomy course for three classes (n = 81 students) from September 2011 to November 2013. The modules were designed around major anatomical regions (thorax; abdomen and pelvis; lower extremities and back; upper extremities; and head and neck) and used various types of simulation (standardized patients, high-fidelity simulators, and task trainers). Several methods were used to evaluate the curriculum's efficacy, including comparing pre- versus posttest scores and comparing posttest scores against the score on 15 clinical correlation final exam questions. OUTCOMES: A total of 81 students (response rate: 100%) completed all pre- and posttests and consented to participate. Posttest scores suggest significant knowledge acquisition and better consistency of performance after participation in the curriculum. The comparison of performance on the posttests and final exam suggests that using simulation as an adjunctive pedagogy can lead to excellent short-term knowledge retention. NEXT STEPS: Simulation-based medical education may prove useful in preclinical basic science curricula. Next steps should be to validate the use of this approach, demonstrate cost-efficacy or the "return on investment" for educational and institutional leadership, and examine longer-term knowledge retention.

Profiling medical school learning environments in Malaysia: a validation study of the Johns Hopkins Learning Environment Scale.

PURPOSE: While a strong learning environment is critical to medical student education, the assessment of medical school learning environments has confounded researchers. Our goal was to assess the validity and utility of the Johns Hopkins Learning Environment Scale (JHLES) for preclinical students at three Malaysian medical schools with distinct educational and institutional models. Two schools were new international partnerships, and the third was school leaver program established without international partnership. METHODS: First- and second-year students responded anonymously to surveys at the end of the academic year. The surveys included the JHLES, a 28-item survey using five-point Likert scale response options, the Dundee Ready Educational Environment Measure (DREEM), the most widely used method to assess learning environments internationally, a personal growth scale, and single-item global learning environment assessment variables. RESULTS: The overall response rate was 369/429 (86%). After adjusting for the medical school year, gender, and ethnicity of the respondents, the JHLES detected differences across institutions in four out of seven domains (57%), with each school having a unique domain profile. The DREEM detected differences in one out of five categories (20%). The JHLES was more strongly correlated than the DREEM to two thirds of the single-item variables and the personal growth scale. The JHLES showed high internal reliability for the total score (α=0.92) and the seven domains (α, 0.56-0.85). CONCLUSION: The JHLES detected variation between learning environment domains across three educational settings, thereby creating unique learning environment profiles. Interpretation of these profiles may allow schools to understand how they are currently supporting trainees and identify areas needing attention.

Learning environment assessments of a single curriculum being taught at two medical schools 10,000 miles apart.

BACKGROUND: Perdana University Graduate School of Medicine (PUGSOM), the first graduate-entry medical school in Malaysia, was established in 2011 in collaboration with Johns Hopkins University School of Medicine (JHUSOM), an American medical school. This study compared learning environments (LE) at these two schools, which shared the same overarching curriculum, along with a comparator Malaysian medical school, Cyberjaya University College of Medical Sciences (CUCMS). As a secondary aim, we compared 2 LE assessment tools - the widely-used Dundee Ready Educational Environment Measure (DREEM) and the newer Johns Hopkins Learning Environment Scale (JHLES). METHODS: Students responded anonymously at the end of their first year of medical school to surveys which included DREEM, JHLES, single-item global LE assessment variables, and demographics questions. RESULTS: Respondents included 24/24 (100 %) students at PUGSOM, 100/120 (83 %) at JHUSOM, and 79/83 (95 %) at CUCMS. PUGSOM had the highest overall LE ratings (p < 0.05) [DREEM 155.3 (SD 21.3); JHLES 116.5 (SD 12.2)], followed by JHUSOM [DREEM 143.3 (SD 22.5); JHLES 111.7 (SD 12.0)] and CUCMS [DREEM 138.5 (SD 22.4); JHLES 106.4 (SD 14.5)]. PUGSOM's overall high LE ratings were driven by responses in "perception of teaching," "meaningful engagement," and "acceptance and safety" domains. JHLES detected significant differences across schools in 5/7 domains and had stronger correlations than DREEM to each global LE assessment variable. CONCLUSIONS: The inaugural class of medical students at PUGSOM rated their LE exceptionally highly, providing evidence that transporting a medical school curriculum may be successful. The JHLES showed promise as a LE assessment tool for use in international settings.

A novel approach to life support training using "action-linked phrases".

BACKGROUND: Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy. METHODS: We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized "There's no pulse", statements and/or actions that followed and whether "Action-Linked Phrases" were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases. RESULTS: Phase I: 62% (42/68) of residents verbalized "there's no pulse" during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating "start compressions". Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30s [IQR:19-42] vs. 150 [IQR:51-242], p < 0.001). Phase II: In BLS courses, the three Action-Linked Phrases were used more frequently in the intervention group: (226/270 [84%] vs. 14/195 [7%]; p < 0.001). In ACLS courses, the six Action-Linked Phrases were uttered more often in the intervention group: (43% [157/368] vs. 23% [46/201], p < 0.001). CONCLUSIONS: Action-Linked Phrases innately used by residents in simulated CPAs were associated with faster initiation of compressions. Action-Linked Phrases were verbalized more frequently if taught as part of a regular BLS or ACLS course. This simple, easy to teach, and easy to implement technique holds promise for impacting cardiac arrest teams' performance of key actions.

Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training.

INTRODUCTION: Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e., "Milestones". We developed a simulation-based teaching approach "Rapid Cycle Deliberate Practice" (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e., "first-five minutes" (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to "try again" over lengthy debriefing. PARTICIPANTS: Pediatric residents from an academic medical center. METHODS: Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation. RESULTS: Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5-100%) vs. post: 34% (26-53%); p<0.001)], no-blow fraction: [pre: 39% (22-64%) median (IQR) vs. post: 30% (22-41%); p=0.01], and pre-shock pause: [pre: 84 s (26-162) vs. post: 8s (4-18); p<0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0-7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03-2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5-5.1)]. CONCLUSIONS: Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

Characteristics of medication use during pediatric medical emergency team events and the role of a pharmacist-provided medication supply.

OBJECTIVES: To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized "pharmacist PMET supply," and the pharmacist's role in implementation and ongoing improvement of a PMET. METHODS: This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. RESULTS: The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the "pharmacist PMET supply." CONCLUSIONS: A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.