The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Guiding, Intermediating, Facilitating, and Teaching (GIFT): A Conceptual Framework for Simulation Educator Roles in Healthcare Debriefing.

INTRODUCTION: Use of frameworks for simulation debriefing represents best practice, although available frameworks provide only general guidance. Debriefers may experience difficulties implementing broad recommendations, especially in challenging debriefing situations that require more specific strategies. This study describes how debriefers approach challenges in postsimulation debriefing. METHODS: Ten experienced simulation educators participated in 3 simulated debriefings. Think-aloud interviews before and after the simulations were used to explore roles that debriefers adopted and the associated strategies they used to achieve specific goals. All data were audio recorded and transcribed, and a constructivist grounded theory approach was used for analysis. RESULTS: 4 roles in debriefing were identified: guiding, (inter)mediating, facilitating integration, and teaching. Each role was associated with specific goals and strategies that were adopted to achieve these goals. The goal of creating and maintaining a psychologically safe learning environment was common across all roles. These findings were conceptualized as the GIFT debriefing framework. CONCLUSIONS: Our findings highlight the multiple roles debriefers play and how these roles are enacted in postsimulation debriefing. These results may inform future professional development and mentorship programs for debriefing in both simulation-based education and healthcare settings.

Approaches to interpersonal conflict in simulation debriefings: A qualitative study.

CONTEXT: Conflict during simulation debriefing can interfere with learning when psychological safety is threatened. Debriefers often feel unprepared to address conflict between learners and the literature does not provide evidence-based guidance within the simulation setting. The purpose of this study was to describe debriefers' approach to mediating interpersonal conflict and explore when, why and how they adopt mediation strategies. METHODS: We performed a secondary analysis of qualitative data collected as part of a larger study examining simulation debriefers' approaches to debriefing scenarios with different learner characteristics. For this study, we applied thematic analysis to transcripts from simulated debriefings (n = 10) and the associated pre-simulation (n = 11) and post-simulation (n = 10) interviews that focused on interpersonal conflict between learners. RESULTS: Debriefers described struggling with mediating conflict and the importance of self-awareness. Specific mediation strategies included intervening, addressing power relations, reconciling unproductive differences, leveraging different perspectives, circumventing the conflict, and shifting beyond the conflict; each of these strategies encompassed a number of particular skills. Situations that triggered a mediation approach were related to psychological safety, emotional intensity, and opportunities for shared understanding and productive learning. Debriefers applied mediation strategies and skills in a flexible and creative way. CONCLUSIONS: The strategies we have described for mediating interpersonal conflict between learners in simulation debriefing align with notions of psychological safety and may be useful in guiding future professional development for simulation educators.

Building impactful systems-focused simulations: integrating change and project management frameworks into the pre-work phase.

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential "pre-work" phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.The goal of this paper is to elucidate the PSI "Pre-work" phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Use of Virtually Facilitated Simulation to Improve COVID-19 Preparedness in Rural and Remote Canada.

Background: The Alberta Health Services' Provincial Simulation Program (eSIM) is Canada's largest simulation program. The eSIM mobile simulation program specializes in delivering simulation-based education (SBE) to rural and remote communities (RRC). During the COVID-19 pandemic, a quality improvement project involving rapid cycle in situ virtually facilitated simulation (VFS) for COVID-19 airway management and health systems preparedness in RRC was successfully implemented. Methods: Between April 24 and July 31, 2020, a team of six rural simulationists (four nurses and two physicians) provided 24 VFS sessions with virtual debriefing to 200 health care providers distributed across 11 RRC in Alberta and the Northwest Territories, covering a geographic area of approximately 169,028 km2. Results: Video analysis of sequential VFS rapid cycle sessions using a standardized observational tool indicated decreased personal protective equipment (PPE) breaches by 36.6% between the first and third cycles. Teams demonstrated increased competency with airway management such as correct use of bag-valve-mask ventilation, and implementation of health system process improvements, such as incorporation of an intubation checklist. Improvements occurred on average over 2.2 rapid cycles completed within 1.3 weeks per RRC. Postsession self-reported participant electronic surveys indicated self-reported improvement in clinical management, teamwork behavior, and health systems issues outcome measures which were categorized based on the Crisis Resource Management and Systems Engineering Initiative for Patient Safety (SEIPS) frameworks. Of the 48 survey respondents, 86.1% reported that VFS was equivalent or superior to in-person simulation. The cost of VFS was 62.9% lower than comparable in-person SBE. Conclusion: VFS provides a rapidly mobilizable and cost-effective way of delivering high-quality SBE to geographically isolated communities.

Cost-effectiveness analysis of workplace-based distributed cardiopulmonary resuscitation training versus conventional annual basic life support training.

Context: Although distributed cardiopulmonary resuscitation (CPR) practice has been shown to improve learning outcomes, little is known about the cost-effectiveness of this training strategy. This study assesses the cost-effectiveness of workplace-based distributed CPR practice with real-time feedback when compared with conventional annual CPR training. Methods: We measured educational resource use, costs, and outcomes of both conventional training and distributed training groups in a prospective-randomised trial conducted with paediatric acute care providers over 12 months. Costs were calculated and reported from the perspective of the health institution. Incremental costs and effectiveness of distributed CPR training relative to conventional training were presented. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER) if appropriate. One-way sensitivity analyses and probabilistic sensitivity analysis were conducted. Results: A total of 87 of 101 enrolled participants completed the training (46/53 in intervention and 41/48 in the control). Compared with conventional training, the distributed CPR training group had a higher proportion of participants achieving CPR excellence, defined as over 90% guideline compliant for chest compression depth, rate and recoil (control: 0.146 (6/41) vs intervention 0.543 (25/46), incremental effectiveness: +0.397) with decreased costs (control: $C266.50 vs intervention $C224.88 per trainee, incremental costs: -$C41.62). The sensitivity analysis showed that when the institution does not pay for the training time, distributed CPR training results in an ICER of $C147.05 per extra excellent CPR provider. Conclusion: Workplace-based distributed CPR training with real-time feedback resulted in improved CPR quality by paediatric healthcare providers and decreased training costs, when training time is paid by the institution. If the institution does not pay for training time, implementing distributed training resulted in better CPR quality and increased costs, compared with conventional training. These findings contribute further evidence to the decision-making processes as to whether institutions/programmes should financially adopt these training programmes.

Correction to: COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

[This corrects the article DOI: 10.1186/s41077-020-00138-w.].

A provincial assessment of readiness for paediatric emergencies: What are the existing resource gaps in Alberta?

OBJECTIVES: A large proportion of all emergency visits for paediatric patients across Canada are to general emergency departments (EDs). These centres may not be adequately equipped to provide optimal care for high acuity paediatric emergencies. The objective of this study was to determine paediatric readiness for general EDs and urgent care centres (UCCs) across Alberta and provide each centre with an overall weighted Paediatric Readiness Score (WPRS). METHODS: A paediatric readiness assessment consisting of 55-questions normalized on a 100-point scale was used to survey 107 general EDs, UCCs, and tertiary paediatric EDs in Alberta, Canada. It addresses six primary categories, including Coordination of Patient Care, Physician/Nurse Staffing and Training, Quality Improvement Activities, Patient Safety Initiatives, Policies and Procedures, and Equipment and Supplies. Descriptive statistics were used to present the WPRS score among different groups. Linear regression models were used to explore factors associated with the score. RESULTS: The overall response rate was 59.8%. The median overall WPRS (/100) for all general EDs and UCCs was 48.4 ([interquartile range {IQR}] 17.6). Factors that were correlated with overall score included high paediatric patient volume (24.28, 95% confidence interval [CI]: 10.52 to 38.04) and involvement in a simulation education outreach program (9.38, 95% CI: 1.11 to 17.66). CONCLUSION: Based on this survey, the WPRS of EDs and UCCs across Alberta suggest a need to improve readiness to respond to high acuity paediatric emergencies in these settings.

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

Healthcare resources have been strained to previously unforeseeable limits as a result of the COVID-19 pandemic of 2020. This has prompted the emergence of critical just-in-time COVID-19 education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. Simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. The individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. Establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. Our provincial simulation program in the province of Alberta, Canada (population = 4.37 million; geographic area = 661,848 km2), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over 400 acute care simulations across our province in both urban and rural Emergency Departments, Intensive Care Units, Operating Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic Imaging and In-patient Units over a 5-week period to an estimated 30,000 learners of real frontline team members. Unfortunately, the speed at which the COVID-19 pandemic has emerged in Canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of COVID-19 patients. Our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. The goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of COVID-19 simulation data across the largest health authority in Canada.

A practical guide to virtual debriefings: communities of inquiry perspective.

Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Virtual debriefings involve educators facilitating conversations through web-based videoconferencing platforms. Facilitating debriefings through a computer interface introduces a unique set of challenges. Educators require practical guidance to support meaningful virtual learning in the transition from in-person to virtual debriefings. The communities of inquiry conceptual framework offer a useful structure to organize practical guidance for conducting virtual debriefings. The communities of inquiry framework describe the three key elements-social presence, teaching presence, and cognitive presence-all of which contribute to the overall learning experience. In this paper, we (1) define the CoI framework and describe its three core elements, (2) highlight how virtual debriefings align with CoI, (3) anticipate barriers to effective virtual debriefings, and (4) share practical strategies to overcome these hurdles.

Managing psychological safety in debriefings: a dynamic balancing act.

Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety-the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a 'safe container' for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.

A Conceptual Framework for the Development of Debriefing Skills: A Journey of Discovery, Growth, and Maturity.

STATEMENT: Despite the critical importance of debriefing in simulation-based education, existing literature offers little guidance on how debriefing skills develop over time. An elaboration of the trajectory through which debriefing expertise evolves would help inform educators looking to enhance their skills. In this article, we present a new conceptual framework for the development of debriefing skills based on a modification of Dreyfus and Dreyfus' model of skill development. For each of the 3 stages of debriefing skill development-discovery, growth, and maturity, we highlight characteristics of debriefers, requisite knowledge, and key skills. We propose how faculty development experiences map to each stage of debriefing skill development. We hope the new conceptual framework will advance the art and science of debriefing by shaping future faculty development initiatives, research, and innovation in debriefing.

PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations.

STATEMENT: Modern healthcare organizations strive for continuous improvement in systems and processes to ensure safe, effective, and cost-conscious patient care. However, systems failures and inefficiencies lurk in every organization, often emerging only after patients have experienced harm or delays. Simulation and debriefing, focused on identifying systems gaps, can proactively lead to improvements in safety and quality. Systems-focused debriefing requires a different approach than traditional, learner-focused debriefing. We describe PEARLS for Systems Integration, a conceptual framework, debriefing structure and script that facilitators can use for systems-focused debriefing. The framework builds on Promoting Excellence And Reflective Learning in Simulation, using common debriefing strategies (plus/delta, focused facilitation, and directive feedback) in a modified format, with new debriefing scripts. Promoting Excellence And Reflective Learning in Simulation for System Integration offers a structured framework, adaptable for debriefing systems-focused simulations, to identify systems issues and maximize improvements in patient safety and quality.

Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers - A randomized controlled trial.

OBJECTIVES: Guideline compliant CPR is associated with improved survival for patients with cardiac arrest. Conventional Basic Life Support (BLS) training results in suboptimal CPR competency and skill retention. We aimed to compare the effectiveness of distributed CPR training with real-time feedback to conventional BLS training for CPR skills in pediatric healthcare providers. METHODS: Healthcare providers were randomized into receiving annual BLS training (control) or distributed training with real-time feedback (intervention). The intervention group was asked to practice CPR for 2 min on mannequins while receiving real-time CPR feedback, at least once per month. Control group participants were not asked to practice CPR during the study period. Excellent CPR was defined as 90% guideline-compliance for depth, rate and recoil of chest compressions. CPR performance of participants was assessed (on infant and adult-sized mannequins) every 3 months for a duration of 12 months. CPR performance was compared between the 2 groups. RESULTS: A total of 87 healthcare providers were included in the analyses (control n = 41, intervention n = 46). Baseline assessment showed no significant difference in CPR performance across the 2 groups. The intervention group has a significantly greater proportion of participants with excellent CPR compared with the control group on an adult sized mannequin (14.6% vs. 54.3%, p < 0.001) and infant-sized mannequin (19.5% vs. 71.7%, p < 0.001) at the end of the study. In the intervention group, all CPR metrics except infant depth were improved and retained over the course of the study. CONCLUSION: Distributed CPR training with real-time feedback improves the compliance of AHA guidelines of quality of CPR.

Establishing a Virtual Community of Practice in Simulation: The Value of Social Media.

STATEMENT: Professional development opportunities are not readily accessible for most simulation educators, who may only connect with simulation experts at periodic and costly conferences. Virtual communities of practice consist of individuals with a shared passion who communicate via virtual media to advance their own learning and that of others. A nascent virtual community of practice is developing online for healthcare simulation on social media platforms. Simulation educators should consider engaging on these platforms for their own benefit and to help develop healthcare simulation educators around the world. Herein, we describe this developing virtual community of practice and offer guidance to assist educators to engage, learn, and contribute to the growth of the community.

Implementing economic evaluation in simulation-based medical education: challenges and opportunities.

CONTEXT: Simulation-based medical education (SBME) is now ubiquitous at all levels of medical training. Given the substantial resources needed for SBME, economic evaluation of simulation-based programmes or curricula is required to demonstrate whether improvement in trainee performance (knowledge, skills and attitudes) and health outcomes justifies the cost of investment. Current literature evaluating SBME fails to provide consistent and interpretable information on the relative costs and benefits of alternatives. CONTENT: Economic evaluation is widely applied in health care, but is relatively scarce in medical education. Therefore, in this paper, using a focus on SBME, we define economic evaluation, describe the key components, and discuss the challenges associated with conducting an economic evaluation of medical education interventions. As a way forward to the rigorous and state of the art application of economic evaluation in medical education, we outline the steps to gather the necessary information to conduct an economic evaluation of simulation-based education programmes and curricula, and describe the main approaches to conducting an economic evaluation. CONCLUSION: A properly conducted economic evaluation can help stakeholders (i.e., programme directors, policy makers and curriculum designers) to determine the optimal use of resources in selecting the modality or method of assessment in simulation. It also helps inform broader decision making about allocation of scarce resources within an educational programme, as well as between education and clinical care. Economic evaluation in medical education research is still in its infancy, and there is significant potential for state-of-the-art application of these methods in this area.

Cognitive Load Theory for debriefing simulations: implications for faculty development.

The debriefing is an essential component of simulation-based training for healthcare professionals, but learning this complex skill can be challenging for simulation faculty. There are multiple competing priorities for a debriefer's attention that can contribute to a high mental workload, which may adversely affect debriefer performance and consequently learner outcomes. In this paper, we conceptualize the debriefer as a learner of debriefing skills and we discuss Cognitive Load Theory to categorize the many potential mental loads that can affect the faculty debriefer as learner. We then discuss mitigation strategies that can be considered by faculty development programmes to enhance professional development of debriefing staff.

The Kids Are Alright: Pediatric Trauma Pearls.

Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.

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.