Hospital to Home: A Quality Improvement Initiative to Implement High-fidelity Simulation Training for Caregivers of Children Requiring Long-term Mechanical Ventilation.

BACKGROUND: Preparing families of children requiring long-term mechanical ventilation (LTMV) to manage medical emergencies at home is challenging. Opportunities for family caregivers to rehearse crisis management in a controlled setting before discharge are limited. OBJECTIVE: We aimed to create a multimodal discharge preparedness curriculum, incorporating high-fidelity simulation training, to prepare family caregivers of children with complex medical conditions requiring long-term mechanical ventilation. We sought to determine which curricular elements were most helpful and whether this curriculum impacted the rate of readmissions within 7 days of hospital discharge. METHODS: The curriculum included instructional videos, printed handouts, cardiopulmonary resuscitation training, and two mandatory high fidelity simulation scenarios depicting tracheostomy- and ventilator-related emergencies. Teams of one to three family caregivers per patient managed each scenario. A video-based debriefing focused on identifying and closing performance gaps. Participants rated their perceptions regarding each curricular element and its relative impact on their preparedness for discharge. RESULTS: 87 family caregivers completed the curriculum. Simulation-enhanced curriculum was well-received by participants. Participants reported that post-simulation debriefing was the most beneficial component. We observed a trend toward reduced readmissions within 7 days of discharge since implementation of our revised curriculum. CONCLUSION: Simulation training can be incorporated into discharge training for families of children requiring LTMV. Rehearsal of emergency management in a simulated clinical setting increases caregiver confidence to assume care for their ventilator-dependent child.

Pediatric respiratory diseases: 2011 update for the Rogers' Textbook of Pediatric Intensive Care.

OBJECTIVES: To review articles relevant to the field of pediatric respiratory disease that were published after the 2008 Rogers' Textbook of Pediatric Intensive Care. DATA SOURCES: The authors searched the PubMed database (http://www.ncbi.nlm.nih.gov/sites/entrez) from the National Library of Medicine for citations from the pediatric and adult literature relevant to pediatric status asthmaticus, bronchiolitis, pneumonia, acute lung injury, acute respiratory distress syndrome, and neonatal respiratory failure. The authors also searched the reference lists of key primary publications and recent review articles, and queried the National Institutes of Health's ClinicalTrials.gov Web site (www.clinicaltrials.gov) to obtain information about ongoing clinical trials for acute lung injury. The authors had knowledge of new publications in the field of respiratory monitoring, which were considered for inclusion in the review. STUDY SELECTION AND DATA EXTRACTION: The authors reviewed the promising articles and the decision to include any article in the review was based on its potential to inform pediatric intensive care practice or future research. DATA SYNTHESIS: Articles in six categories were selected for inclusion: status asthmaticus, bronchiolitis, pneumonia, acute lung injury/acute respiratory distress syndrome, respiratory monitoring, and neonatal respiratory failure. CONCLUSIONS: There have been important new developments relevant to the pathogenesis and management of pediatric respiratory diseases. In particular, new insights into the causal pathways of respiratory syncytial virus-induced airways disease can potentially lead to novel therapies. Computed tomography imaging of the injured lung during mechanical ventilation has opened new avenues for future research directed at testing new treatments in acute lung injury subpopulations defined according to lung mechanics. Promising new monitoring techniques may play a supporting role in the conduct of these studies. Finally, evidence from the neonatal literature recently has shown how the course and future consequences of respiratory failure in this population may be modified through more widespread use of noninvasive support.

Performance of a consensus scoring algorithm for assessing pediatric advanced life support competency using a computer screen-based simulator.

OBJECTIVE: To develop a computer screen-based simulator that may be used as a pediatric advanced life support (PALS) cognitive skill assessment tool and to pilot test a consensus-based scoring system for the simulator. DESIGN: Development of an evaluation tool, followed by prospective, observational study of tool performance. SETTING: Tertiary care pediatric hospital. SUBJECTS: A total of 100 PALS providers from multiple disciplines. INTERVENTIONS: Using a consensus process with a group of six experts in pediatric emergency and critical care medicine, we developed scoring algorithms to measure performance on four interactive PALS scenarios (supraventricular tachycardia, pulseless electrical activity, ventricular fibrillation, and bradycardia). PALS providers (n = 100) completed the scenarios on the simulator and the computer assessed their performance using the scoring algorithm. MEASUREMENTS AND MAIN RESULTS: Case management scoring audits agreed 100% with computer scoring during pilot testing, indicating excellent reliability. The mean time to complete all four cases was 13.8 mins. Performance scores were highest for supraventricular tachycardia management and lowest for pulseless electrical activity management. Survival was significantly more common than death in the supraventricular tachycardia and ventricular fibrillation scenarios, whereas death was more common in the pulseless electrical activity scenario (p < .004). Physician status predicted a higher aggregate score as well as higher scores in the supraventricular tachycardia (p < .001), pulseless electrical activity (p = .041), and bradycardia (p = .006) scenarios. Participants who completed the PALS course on the same day as their assessment scored higher on the supraventricular tachycardia scenario (p = .041). CONCLUSIONS: Personal computer-based simulation can be used to evaluate performance against consensus criteria in a large number of PALS providers. This technology could supplement traditional curricula by facilitating frequent knowledge assessments as part of a PALS competency maintenance regimen.

Efficacy of interventions for bronchiolitis in critically ill infants: a systematic review and meta-analysis.

BACKGROUND: Viral bronchiolitis is the leading cause of respiratory failure among infants in the United States. Currently, the mainstay of treatment is supportive care. The effectiveness of treatments used for mechanically ventilated infants with bronchiolitis is unclear. OBJECTIVE: To evaluate the strength of the evidence supporting the use of currently available treatments for critically ill infants with bronchiolitis. DATA SOURCE: We searched PubMed, citations of relevant articles, personal files, and conference proceedings, and we contacted experts in the field. STUDY SELECTION: Randomized, controlled trials evaluating any therapy for bronchiolitis that included children in an intensive care unit. DATA EXTRACTION: Two reviewers independently extracted data and assessed methodologic quality. DATA SYNTHESIS: A total of 2,319 citations were screened, and 16 randomized, controlled trials were included. There were three trials of surfactant, three of ribavirin, three of immune globulin, three of systemic corticosteroids, and one each of vitamin A, interferon, erythropoietin, and heliox. A meta-analysis of the three surfactant studies showed a strong trend toward a decrease in duration of mechanical ventilation of 2.58 days (95% confidence interval, -5.34 to 0.18 days; p =.07) and a significant decrease of 3.3 intensive care unit days (95% confidence interval, -6.38 to -0.23 days; p =.04). A meta-analysis of the three systemic corticosteroid studies showed no overall effect on duration of mechanical ventilation when all three trials were combined (-0.62 day; 95% confidence interval, -2.78 to 1.53 days; p =.57). We identified one published meta-analysis of three ribavirin studies showing a significant decrease in ventilator days with ribavirin (-1.2 days; 95% confidence interval, -0.2 to -3.4 days; p =.2). CONCLUSIONS: Currently, there are no clearly effective interventions available to improve the outcome of critically ill infants with bronchiolitis. Surfactant seems to be a promising intervention, and corticosteroids or ribavirin may also be beneficial.

Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit.

INTRODUCTION: Relocating obstetric (OB) services to a children's hospital imposes demands on facility operations, which must be met to ensure quality care and a satisfactory patient experience. We used in situ simulations to prospectively and iteratively evaluate operational readiness of a children's hospital-based OB unit before it opened for patient care. METHODS: This project took place at a 314-bed, university-affiliated children's hospital. We developed 3 full-scale simulation scenarios depicting a concurrent maternal and neonatal emergency. One scenario began with a standardized patient experiencing admission; the mannequin portrayed a mother during delivery. We ran all 3 scenarios on 2 dates scheduled several weeks apart. We ran 2 of the scenarios on a third day to verify the reliability of key processes. During the simulations, content experts completed equipment checklists, and participants identified latent safety hazards. Each simulation involved a unique combination of scheduled participants who were supplemented by providers from responding ancillary services. RESULTS: The simulations involved 133 scheduled participants representing OB, neonatology, and anesthesiology. We exposed and addressed operational deficiencies involving equipment availability, staffing, interprofessional communication, and systems issues such as transfusion protocol failures and electronic order entry challenges. Process changes between simulation days 1 to 3 decreased the elapsed time between transfusion protocol activation and blood arrival to the operating room and labor/delivery/recovery/postpartum setting. CONCLUSIONS: In situ simulations identified multiple operational deficiencies on the OB unit, allowing us to take corrective action before its opening. This project may guide other children's hospitals regarding care processes likely to require significant focus and possible modification to accommodate an OB service.

Evaluating the efficacy of the AAP "pediatrics in disaster" course: the Chinese experience.

OBJECTIVE: "Pediatrics in Disasters" (PEDS) is a course designed by the American Academy of Pediatrics to provide disaster preparedness and response training to pediatricians worldwide. China has managed to sustain the course and adapt its content for local needs. China has also experienced several natural disasters since the course's inception, providing an opportunity to evaluate the impact of courses that took place in Beijing and Sichuan, in 2008-2010. METHODS: We used pretesting/post-testing, participant surveys, and in-depth interviews to evaluate whether the course imparted cognitive knowledge, was perceived as useful, and fostered participation in relief efforts and disaster preparedness planning. RESULTS: In Beijing and Sichuan, post-test scores were 16 percent higher than pretest scores. On immediate postcourse surveys, 86 percent of Beijing and Sichuan respondents rated the course as very good or excellent. On 6-month surveys, participants identified emotional impact of disasters, planning/triage, and nutrition as the three most useful course modules. Twelve of 75 (16 percent) of Beijing respondents reported direct involvement in disaster response activities following the course; eight of 12 were first-time responders. Participant interviews revealed a need for more training in providing nutritional and psychological support to disaster victims and to train a more diverse group of individuals in disaster response. CONCLUSIONS: PEDS imparts cognitive knowledge and is highly valued by course participants. Emotional impact of disasters, planning/triage, and nutrition modules were perceived as the most relevant modules. Future versions of the course should include additional emphasis on emotional care for disaster victims and should be extended to a broader audience.

End-user evaluations of a personal computer-based pediatric advanced life support simulator.

INTRODUCTION: : To inform further development of a personal computer-based Pediatric Advanced Life Support (PALS) simulator, we wished to understand users' perceptions of this new technology. Specifically, we sought to determine whether the simulator was perceived as an effective training tool, whether it filled a gap in the users' current training regimen, and whether these perceptions were impacted by professional affiliation and PALS training history. METHODS: : We surveyed multidisciplinary health care workers in a tertiary care pediatric hospital who used our simulator. RESULTS: : A total of 789 users completed an evaluation of the simulator. Ninety-five percent of respondents agreed that the PALS simulator is an effective educational tool. Eighty-nine percent agreed that the simulator filled a gap in their training, although physicians agreed with this statement more strongly than nurses (P = 0.001). Prior resuscitation training history did not impact whether users perceived that the simulator filled a curricular gap. Users most commonly cited the simulator's realism, its capacity to facilitate practice, and its help feature as the top three qualities they most appreciated. Users' top three suggestions for improving the simulator included provision of a structured tutorial, specific user interface improvements, and encouragement of more widespread access to the simulator. CONCLUSIONS: : Hospital-based pediatric providers are open to using personal computer-based simulation to provide on-demand refresher training in the cognitive aspects of PALS. Through its capacity to reach a large number of health care workers without the need for instructor presence, this technology could be used to help develop a more targeted role for mannequin simulation.

Factors influencing nurses' attitudes toward simulation-based education.

OBJECTIVE: To identify barriers to nurses' participation in simulation, and to determine whether prior simulation exposure, professional experience, and practice location influence their tendency to perceive specific issues as barriers. We also sought to identify nurses' educational priorities, and to determine whether these were influenced by years of experience or practice location. METHODS: We surveyed full-time and part-time nurses in a university-affiliated children's hospital to gather data on professional demographics, simulation exposure, perceived barriers to participation in simulation, and training priorities. RESULTS: A total of 523 of 936 (56%) eligible nurses completed the survey. Binary logistic regression analysis revealed that "simulation is 'not the real thing'" was selected as a barrier more often by nurses with prior simulation experience (P = 0.02), fewer years in practice (P = 0.02), and employment in non-acute care areas of the hospital (P = 0.03). "Unfamiliarity with equipment" was reported more often by nurses with less experience (P = 0.01). "Stressful or intimidating environment" was selected more often by those who work in non-acute care areas (P < 0.01). "Providing opportunities to manage rare events" was suggested as a training priority by nurses with less experience (P = 0.08) and by those practicing in acute care areas (P = 0.03). CONCLUSIONS: We identified several barriers to nurses' participation in simulation training. Nurses' tendency to name specific issues as barriers is related to prior simulation exposure, years of experience, and area of hospital practice. Rehearsing rare event management is a priority for less-experienced nurses and those in acute care areas.

High frequency oscillatory ventilation in acute respiratory failure.

High frequency oscillatory ventilation (HFOV) has emerged over the past 20 years as a safe and effective means of mechanical ventilatory support in patients with acute respiratory failure. During HFOV, lung recruitment is maintained by application of a relatively high mean airway pressure with superimposed pressure oscillations at a frequency of 3 to 15Hz, creating adequate ventilation using tidal volumes less than or equal to the patient's dead space volume. The physiologic rationale for the application of HFOV in the clinical arena comes from its ability to preserve end-expiratory lung volume while avoiding parenchymal overdistension at end-inspiration and theoretically limiting the potential for ventilator-associated lung injury. Data in the neonatal population suggests significant benefits in pulmonary outcomes when HFOV is applied with a recruitment strategy in preterm infants with respiratory distress syndrome (RDS). Use of HFOV in the paediatric and adult populations has not as yet been associated with significant improvements in clinically important outcome measures.