Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program.

BACKGROUND: The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. METHODS: This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. RESULTS: We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. CONCLUSIONS: We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

The effectiveness of a novel colorant additive in the daily cleaning of patient rooms.

The quality of daily cleaning was assessed comparing a standard bleach product with the bleach product containing a novel colorant additive in an inpatient setting. Effectiveness was assessed using fluorescent markings and microbiological analysis of environmental and experimental specimens. Our findings showed no significant difference in cleaning between these groups.

PROcess for the Design of User-Centered Environments (PRODUCE): Guiding Change in the Health Care Environment.

Changes in the physical environments of health care settings have become increasingly common to meet the evolving needs of the health care marketplace, new technologies, and infrastructure demands. Physical environment change takes many forms including new build construction, renovation of existing space, and relocation of units with little to no construction customization. The interrelated nature of the complex socio-technical health care system suggests that even small environmental modifications can result in system-level changes. Environmental modifications can lead to unintended consequences and introduce the potential for latent safety threats. Engaging users throughout the change lifecycle allows for iterative design and testing of system modifications. This chapter introduces a flexible process model, PROcess for the Design of User-Centered Environments (PRODUCE), designed to guide system change. The model was developed and refined across a series of real-world renovations and relocations in a large multihospital health care system. Utilizing the principles of user-centered design, human factors, and in-situ simulation, the model engages users in the planning, testing, and implementation of physical environment change. Case studies presented here offer exemplars of how to modify the model to support individual project objectives and outcomes to assess at each stage of the project.

Workload of Team Leaders and Team Members During a Simulated Sepsis Scenario.

OBJECTIVES: Crisis resource management principles dictate appropriate distribution of mental and/or physical workload so as not to overwhelm any one team member. Workload during pediatric emergencies is not well studied. The National Aeronautics and Space Administration-Task Load Index is a multidimensional tool designed to assess workload validated in multiple settings. Low workload is defined as less than 40, moderate 40-60, and greater than 60 signify high workloads. Our hypothesis is that workload among both team leaders and team members is moderate to high during a simulated pediatric sepsis scenario and that team leaders would have a higher workload than team members. DESIGN: Multicenter observational study. SETTING: Nine pediatric simulation centers (five United States, three Canada, and one United Kingdom). PATIENTS: Team leaders and team members during a 12-minute pediatric sepsis scenario. INTERVENTIONS: National Aeronautics and Space Administration-Task Load Index. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-seven teams were recruited from nine sites. One hundred twenty-seven team leaders and 253 team members completed the National Aeronautics and Space Administration-Task Load Index. Team leader had significantly higher overall workload than team member (51 ± 11 vs 44 ± 13; p < 0.01). Team leader had higher workloads in all subcategories except in performance where the values were equal and in physical demand where team members were higher than team leaders (29 ± 22 vs 18 ± 16; p < 0.01). The highest category for each group was mental 73 ± 13 for team leader and 60 ± 20 for team member. For team leader, two categories, mental (73 ± 17) and effort (66 ± 16), were high workload, most domains for team member were moderate workload levels. CONCLUSIONS: Team leader and team member are under moderate workloads during a pediatric sepsis scenario with team leader under high workloads (> 60) in the mental demand and effort subscales. Team leader average significantly higher workloads. Consideration of decreasing team leader responsibilities may improve team workload distribution.

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.

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy.

BACKGROUND: GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). PURPOSES: This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. METHODS: Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. RESULTS: Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. CONCLUSIONS: A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

Simulation-based training in brain death determination.

BACKGROUND: Despite straightforward guidelines on brain death determination by the American Academy of Neurology (AAN), substantial practice variability exists internationally, between states, and among institutions. We created a simulation-based training course on proper determination based on the AAN practice parameters to address and assess knowledge and practice gaps at our institution. METHODS: Our intervention consisted of a didactic course and a simulation exercise, and was bookended by before and after multiple-choice tests. The 40-min didactic course, including a video demonstration, covered all aspects of the brain death examination. Simulation sessions utilized a SimMan 3G manikin and involved a complete examination, including an apnea test. Possible confounders and signs incompatible with brain death were embedded throughout. Facilitators evaluated performance with a 26-point checklist based on the most recent AAN guidelines. A senior neurologist conducted all aspects of the course, including the didactic session, simulation, and debriefing session. RESULTS: Ninety physicians from multiple specialties have participated in the didactic session, 38 of whom have completed the simulation. Pre-test scores were poor (41.4 %), with attendings scoring higher than residents (46.6 vs. 40.4 %, p = 0.07), and neurologists and neurosurgeons significantly outperforming other specialists (53.9 vs. 38.9 %, p = 0.003). Post-test scores (73.3 %) were notably higher than pre-test scores (45.4 %). Participant feedback has been uniformly positive. CONCLUSION: Baseline knowledge of brain death determination among providers was low but improved greatly after the course. Our intervention represents an effective model that can be replicated at other institutions to train clinicians in the determination of brain death according to evidence-based guidelines.

Theoretical foundations of learning through simulation.

Health care simulation is a powerful educational tool to help facilitate learning for clinicians and change their practice to improve patient outcomes and safety. To promote effective life-long learning through simulation, the educator needs to consider individuals, their experiences, and their environments. Effective education of adults through simulation requires a sound understanding of both adult learning theory and experiential learning. This review article provides a framework for developing and facilitating simulation courses, founded upon empiric and theoretic research in adult and experiential learning. Specifically, this article provides a theoretic foundation for using simulation to change practice to improve patient outcomes and safety.

The 3D model of debriefing: defusing, discovering, and deepening.

The experiential learning process involves participation in key experiences and analysis of those experiences. In health care, these experiences can occur through high-fidelity simulation or in the actual clinical setting. The most important component of this process is the postexperience analysis or debriefing. During the debriefing, individuals must reflect upon the experience, identify the mental models that led to behaviors or cognitive processes, and then build or enhance new mental models to be used in future experiences. On the basis of adult learning theory, the Kolb Experiential Learning Cycle, and the Learning Outcomes Model, we structured a framework for facilitators of debriefings entitled "the 3D Model of Debriefing: Defusing, Discovering, and Deepening." It incorporates common phases prevalent in the debriefing literature, including description of and reactions to the experience, analysis of behaviors, and application or synthesis of new knowledge into clinical practice. It can be used to enhance learning after real or simulated events.

High-fidelity medical simulation as a technique to improve pediatric residents' emergency airway management and teamwork: a pilot study.

OBJECTIVE: High-fidelity medical simulation is a technique used for training residents. Simulation is used to teach procedural skills and teamwork. There are limited data on the efficacy of this educational technique. We hypothesize that simulation is effective for teaching pediatric residents airway skills and teamwork. METHODS: We performed a randomized crossover trial with 16 postgraduate year 2 residents at the Rhode Island Hospital Medical Simulation Center. The residents were given a standard introduction to the simulation center then managed 2 scenarios, during which baseline airway and teamwork skills were assessed. The participants were divided into 2 groups. Group 1 returned for a simulation-enhanced session on pediatric airway management and teamwork, whereas group 2 received no supplemental education. Two months later, groups 1 and 2 were reassessed. Subsequently, group 2 returned for the same intervention as group 1. Both groups returned for a final assessment. RESULTS: Data were collected using the Rhode Island Hospital Medical Simulation Center global competency score, critical action checklists, harmful actions lists, and the Behaviorally Anchored Rating Scale. The mean global competency score improved and showed a statistically significant relationship between the intervention and the performance. Critical actions showed a statistically insignificant trend of improvement. There was a striking reduction in the number of harmful actions. The Behaviorally Anchored Rating Scale improved at each session though statistically unrelated to the intervention. CONCLUSIONS: This study supports simulation-enhanced educational strategies for improving performance and teamwork skills. This technique is effective in teaching pediatric residents airway skills and teamwork fundamentals required to efficiently manage an acute airway situation.

High-fidelity medical simulation as an assessment tool for pediatric residents' airway management skills.

OBJECTIVES: To evaluate high-fidelity medical simulation as an assessment tool for pediatric residents' ability to manage an acute airway. METHODS: We performed a prospective, observational study in which 16 pediatric residents were consented and then brought to the medical simulation center. They were placed in 2 different computer-driven scenarios and asked to manage the cases. The first scenario was a 3-month-old infant with bronchiolitis and severe respiratory distress and was programmed to develop respiratory failure. The second case was a 16-year-old adolescent with alcohol intoxication and respiratory depression and was programmed for emesis and aspiration. Both cases included a nurse, parent, and intern. We recorded performance of predetermined critical actions and any harmful actions. RESULTS: There were 47 attempts at intubation with 27 successes (56%). Appropriate preoxygenation was performed in 15 (47%) of 32 cases. Appropriate rapid sequence induction was administered in 21 (66%) of 32 cases. Cricoid pressure was applied in 20 (63%) of 32 cases. End-tidal carbon dioxide detector was used in 11 (34%) of 32 cases. A nasogastric tube was placed in 14 (44%) of 32 cases. Harmful actions included rapid sequence induction administered before intubation equipment setup, bag-valve mask not connected to oxygen, inappropriate endotracheal tube size, pulling cuffed endotracheal tube out while inflated, and placing the laryngoscope blade on backwards. CONCLUSIONS: Our data identified many areas of concern with resident skills in managing an airway. This project suggests that high-fidelity medical simulation can assess a resident's ability to manage an airway as well as a program's effectiveness in teaching the skills necessary to manage an acute pediatric airway.