Debriefer cognitive load during Traditional Reflective Debriefing vs. Rapid Cycle Deliberate Practice interdisciplinary team training.

BACKGROUND: Cognitive load impacts performance of debriefers and learners during simulations, but limited data exists examining debriefer cognitive load. The aim of this study is to compare the cognitive load of the debriefers during simulation-based team training (SbTT) with Rapid Cycle Deliberate Practice (RCDP) debriefing and Traditional Reflective Debriefing (TRD). We hypothesize that cognitive load will be reduced during RCDP compared to TRD. METHODS: This study was part of a large-scale, interdisciplinary team training program at Children's Healthcare of Atlanta Egleston Pediatric Emergency Department, with 164 learners (physicians, nurses, medical technicians, paramedics, and respiratory therapists (RTs)). Eight debriefers (main facilitators and discipline-specific coaches) led 28 workshops, which were quasi-randomized to either RCDP or TRD. Each session began with a baseline medical resuscitation scenario and cognitive load measurement using the NASA Task Load Index (TLX), and the NASA TLX was repeated immediately following either TRD or RCDP debriefing. Raw scores of the NASA TLX before and after intervention were compared. ANOVA tests were used to compare differences in NASA TLX scores before and after intervention between the RCDP and TRD groups. RESULTS: For all debriefers, mean NASA TLX scores for physical demands and frustration significantly decreased (- 0.8, p = 0.004 and - 1.3, p = 0.002) in TRD and mean perceived performance success significantly increased (+ 2.4, p < 0.001). For RCDP, perceived performance success increased post-debriefing (+ 3.6, p < 0.001), time demands decreased (- 1.0, p = 0.04), and frustration decreased (- 2.0, p < 0.001). Comparing TRD directly to RCDP, perceived performance success was greater in RCDP than TRD (3.6 vs. 2.4, p = 0.04). Main facilitators had lower effort and mental demand in RCDP and greater perceived success (p < 0.001). CONCLUSION: RCDP had greater perceived success than TRD for debriefers. Main facilitators also report reduced effort and baseline mental demand in RCDP. For less experienced debriefers, newer simulation programs, or large team training sessions such as our study, RCDP may be a less mentally demanding debriefing methodology for facilitators.

A comparison of rapid cycle deliberate practice and traditional reflective debriefing on interprofessional team performance.

BACKGROUND: In simulation-based education, debriefing is necessary to promote knowledge acquisition and skill application. Rapid Cycle Deliberate Practice (RCDP) and Traditional Reflective Debriefing (TRD) are based in learning theories of deliberate practice and reflective learning, respectively. In this study, we compared the effectiveness of TRD versus RCDP on acquisition of conceptual knowledge and teamwork skills among interdisciplinary learners in the pediatric emergency department. METHODS: One hundred sixty-four learners including emergency department attending physicians, fellows, nurses, medical technicians, paramedics, and respiratory therapists, participated in 28 in-situ simulation workshops over 2 months. Groups were quasi-randomized to receive RCDP or TRD debriefing. Learners completed a multiple-choice test to assess teamwork knowledge. The TEAM Assessment Tool assessed team performance before and after debriefing. Primary outcomes were teamwork knowledge and team performance. RESULTS: Average pre-intervention baseline knowledge assessment scores were high in both groups (TRD mean 90.5 (SD 12.7), RCDP mean 88.7 (SD 15.5). Post-test scores showed small improvements in both groups (TRD mean 93.2 (SD 12.2), RCDP mean 89.9 (SD 13.8), as indicated by effect sizes (ES = 0.21 and 0.09, for TRD and RCDP, respectively). Assessment of team performance demonstrated a significant improvement in mean scores from pre-assessment to post-assessment for all TEAM Assessment skills in both TRD and RCDP arms, based on p-values (all p < 0.01) and effect sizes (all ES > 0.8). While pre-post improvements in TEAM scores were generally higher in the RCDP group based on effect sizes, analysis did not indicate either debriefing approach as meaningfully improved over the other. CONCLUSIONS: Our study did not demonstrate that either TRD versus RCDP was meaningfully better in teamwork knowledge acquisition or improving skill application and performance. As such, we propose Reflective Deliberate Practice as a framework for future study to allow learners to reflect on learning and practice in action.

Let us to the TWISST; Plan, Simulate, Study and Act.

Translational Work Integrating Simulation and Systems Testing (TWISST) is a novel application of simulation that augments how we discover, understand, and mitigate errors in our system. TWISST is a diagnostic and interventional tool that couples Simulation-based Clinical Systems Testing with simulation-based training (SbT). TWISST tests environments and work systems to identify latent safety threats (LSTs) and process inefficiencies. In SbT, improvements made to the work system are embedded in hard wire system improvements, ensuring optimal integration into clinical workflow. Methods: Simulation-based Clinical Systems Testing approach includes simulated scenarios, Summarize, Anchor, Facilitate, Explore, Elicit debriefing, and Failure Mode and Effect Analysis. In iterative Plan-Simulate-Study-Act cycles, frontline teams explored work system inefficiencies, identified LSTs, and tested potential solutions. As a result, system improvements were hardwired through SbT. Finally, we present a case study example of the TWISST application in the Pediatric Emergency Department. Results: TWISST identified 41 latent conditions. LSTs were related to resource/equipment/supplies (n = 18, 44%), patient safety (n = 14, 34%), and policies/procedures (n = 9, 22%). Work system improvements addressed 27 latent conditions. System changes that eliminated waste or modified the environment to support best practices mitigated 16 latent conditions. System improvements that addressed 44% of LSTs cost the department $11,000 per trauma bay. Conclusions: TWISST is an innovative and novel strategy that effectively diagnoses and remediates LSTs in a working system. This approach couples highly reliable work system improvements and training into 1 framework.

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey.

OBJECTIVES: Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown. DESIGN: Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test. SETTING: Internet-based survey. SUBJECTS: U.S. PICU representatives (one per institution) involved in resuscitation systems of care. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02). CONCLUSIONS: The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.

Survey of Current Institutional Practices in the Use of High-Flow Nasal Cannula for Pediatric Patients.

OBJECTIVES: High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States. METHODS: Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis. RESULTS: Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline. CONCLUSIONS: Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC.

Simulation-based User-centered Design: An Approach to Device Development during COVID-19.

INTRODUCTION: Since the onset of COVID-19, intubations have become very high risk for clinical teams. Barrier devices during endotracheal intubation protect clinicians from the aerosols generated. Simulation-based user-centered design (UCD) was an iterative design process used to develop a pediatric intubation aerosol containment system (IACS). Simulation was anchored in human factor engineering and UCD to better understand clinicians' complex interaction with the IACS device, elicit user wants and needs, identify design inefficiencies, and unveil safety concerns. METHODS: This study was a prospective observational study of a simulation-based investigation used to design a pediatric IACS rapidly. Debriefing and Failure Mode and Effect Analysis identified latent conditions related to 5 device prototypes. Design iterations made were based on feedback provided to the engineering team after each simulation. RESULTS: Simulation identified 32 latent conditions, resulting in 5 iterations of the IACS prototype. The prototypes included an (1) intubation box; (2) IACS shield; (3) IACS frame with PVC pipes; (4) IACS plexiglass frame, and finally, (5) IACS frame without a plexiglass top. CONCLUSIONS: Integration of simulation with human factor ergonomics and UCD, in partnership with mechanical engineers, facilitated a novel context to design and redesign a pediatric IACS to meet user needs and address safety concerns.

Translational Simulation Improves Compliance with the NEAR4KIDS Airway Safety Bundle in a Single-center PICU.

The National Emergency Airway Registry for Children (NEAR4KIDS) Airway Safety Quality Improvement (QI) Bundle is a QI tool to improve the safety of tracheal intubations. The ability to achieve targeted compliance with bundle adherence is a challenge for centers due to competing QI initiatives, lack of interdisciplinary involvement, and time barriers. We applied translational simulations to identify safety and performance gaps contributing to poor compliance and remediate barriers by delivering simulation-based interventions. METHODS: This was a single-center retrospective review following translational simulations to improve compliance with the NEAR4KIDS bundle . The simulation was implemented between March 2018 and December 2018. Bundle adherence was assessed 12 months before simulation and 9 months following simulation. Primary outcomes were compliance with the bundle and utilization of apneic oxygenation. The secondary outcome was the occurrence of adverse tracheal intubation-associated events. RESULTS: Preintervention bundle compliance was 66%, and the application of apneic oxygenation was 27.9%. Following the simulation intervention, bundle compliance increased to 93.7% (P < 0.001) and adherence to apneic oxygenation increased to 77.9% (P < 0.001). There was no difference in the occurrence of tracheal intubation-associated events. CONCLUSIONS: Translational simulation was a safety tool that improved NEAR4KIDS bundle compliance and elucidated factors contributing to successful implementation. Through simulation, we optimized bundle customization through process improvement, fostered a culture of safety, and effectively engaged multidisciplinary teams in this quality initiative to improve adherence to best practices surrounding tracheal intubations.

Mortality and Outcomes of Pediatric Tracheostomy Dependent Patients.

Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children. Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death. Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5-19.5 months) and 23.8 months (IQR 9.9-46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1-29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76-88%) and 68% (95% CI: 57-76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04-3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04). Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.

SAFEE: A Debriefing Tool to Identify Latent Conditions in Simulation-based Hospital Design Testing.

In the process of hospital planning and design, the ability to mitigate risk is imperative and practical as design decisions made early can lead to unintended downstream effects that may lead to patient harm. Simulation has been applied as a strategy to identify system gaps and safety threats with the goal to mitigate risk and improve patient outcomes. Early in the pre-construction phase of design development for a new free-standing children's hospital, Simulation-based Hospital Design Testing (SbHDT) was conducted in a full-scale mock-up. This allowed healthcare teams and architects to actively witness care providing an avenue to study the interaction of humans with their environment, enabling effectively identification of latent conditions that may lay dormant in proposed design features. In order to successfully identify latent conditions in the physical environment and understand the impact of those latent conditions, a specific debriefing framework focused on the built environment was developed and implemented. This article provides a rationale for an approach to debriefing that specifically focuses on the built environment and describes SAFEE, a debriefing guide for simulationists looking to conduct SbHDT.

A Survey Assessing Pediatric Transport Team Composition and Training.

OBJECTIVE: The aim of this study was to assess national pediatric/neonatal specialty transport teams' composition and training requirements to determine if any current standardization exists. METHODS: This was a survey of the transport teams listed with the American Academy of Pediatrics via SurveyMonkey. RESULTS: While most of the teams maintain internal criteria for team competency and training, there is large variation across team compositions. The vast majority of the teams have a nurse-led team with the addition of another nurse, medic, and/or respiratory therapist regardless of mode of transport. Many of the teams report adjusting team composition based on acuity. Fewer than 15% of teams have a physician as a standard team member. More than 80% required a minimum number of supervised intubations prior to independent practice; however, the number varied largely from as little as 3 to as many as 30. Eighty-eight percent of the teams report using simulation as part of their education program, but again there were marked differences between teams as to how it was used. CONCLUSIONS: There is tremendous variability nationally among pediatric/neonatal transport teams regarding training requirements, certifications, and team composition. The lack of standardization regarding team member qualifications or maintenance of competency among specialized transport teams should be looked at more closely, and evidence-based guidelines may help lead to further improved outcomes in the care of critically ill pediatric patients in the prehospital setting.

Can Simulation Based-Team Training Impact Bedside Teamwork in a Pediatric Intensive Care Unit?

Effective teamwork performance is essential to the delivery of high-quality and safe patient care. In this mixed methodological observational cohort study, we evaluated team performance immediately following a real medical crisis in a pediatric intensive care unit (PICU) following implementation of a simulation-based team training (SBTT) program. Comparison of teamwork skills when rated by study observers demonstrated a statistically significant improvement in 12 out of 15 composite teamwork skills during real emergency events following SBTT ( p < 0.05). Pre- and post-SBTT intervention survey data demonstrated an improvement in the perception of teamwork, most notable in the area of shared mental model and situational awareness following SBTT. Study results suggest that teamwork behaviors and skills acquired during SBTT can translate into improved bedside performance in the PICU.

Promoting Teamwork for Rapid Response Teams Through Simulation Training.

Use of teamwork skills during rapid response calls is important in the management of patient decompensation outside of the intensive care unit. The ability of a rapid response team (RRT) to influence patient outcomes depends on early team building and effective team performance. Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills. Rapid Cycle Deliberate Practice (RCDP) is becoming increasingly popular in simulation-based education. Emerging literature on the application of RCDP suggests this method may be superior to traditional reflective debriefing (TRD) in the acquisition of technical skills related to medical management, but fewer data exist that evaluate application of RCDP in teaching nontechnical teamwork skills. We describe a blended approach, using TRD with RCDP to hardwire teamwork behaviors including role assignment, task delegation, situational awareness, global assessment, and shared mental model to a nursing-led RRT. [J Contin Educ Nurs. 2019;50(11):523-528.].

Prevent Safety Threats in New Construction through Integration of Simulation and FMEA.

INTRODUCTION: The built environment may impact safety and decisions made during the design phases can have unintended downstream effects that lead to patient harm. These flaws within the system are latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) provides a clinical context to examine the environment for safety threats postconstruction. Integration of Failure Mode Effect Analysis (FMEA) with SbCST provides a framework to identify, categorize, and prioritize LSTs before patient exposure. METHODS: We implemented SbCST in a newly constructed pediatric subspecialty outpatient center before opening. We used in-situ simulations to evaluate both routine and high-risk clinical scenarios pertinent to each clinical area. FMEA was used as a methodology to assign risk, prioritize, and categorize LSTs identified during the simulation. RESULTS: Over 3 months, we conducted 31 simulated scenarios for 15 distinct subspecialty clinics involving 150 participants and 151 observers. We identified a total of 334 LSTs from 15 distinct clinics. LSTs were further classified into process/workflow, facility, resource, or clinical performance issues. CONCLUSIONS: Integration of SbCST and FMEA risk assessment is effective in evaluating a new space for safety threats, workflow, and process inefficiencies in the postconstruction environment, providing a framework for prioritizing issues with the greatest risk for harm.

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.

Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.

Simulation-Based Palliative Care Communication for Pediatric Critical Care Fellows.

BACKGROUND: Pediatric palliative care (PPC) education is lacking in pediatric critical care medicine (PCCM) fellowships, despite the desire of many program directors and fellows to expand difficult conversation training. Simulation-based training is an experiential method for practicing challenging communication skills such as breaking bad news, disclosing medical errors, navigating goals of care, and supporting medical decision-making. METHODS: We describe a simulation-based PPC communication series for PCCM fellows, including presimulation session, simulation session, debriefing, and evaluation methods. From 2011 to 2017, 28 PCCM fellows participated in a biannual half-day simulation session. Each session included 3 scenarios (allowing for participation in up to 18 scenarios over 3 years). Standardized patients portrayed the child's mother. PCCM and interprofessional PPC faculty cofacilitated, evaluated, and debriefed the fellows after each scenario. Fellows were evaluated in 4 communication categories (general skills, breaking bad news, goals of care, and resuscitation) using a 3-point scale. A retrospective descriptive analysis was conducted. RESULTS: One hundred sixteen evaluations were completed for 18 PCCM fellows. Median scores for general communication items, breaking bad news, and goals of care ranged from 2.0 to 3.0 (interquartile range [IQR]: 0-1) with scores for resuscitation lower at 1.0 (IQR: 1.5-2). DISCUSSION: This experiential simulation-based PPC communication curriculum taught PCCM fellows valuable palliative communication techniques although revealed growth opportunities within more complex communication tasks. The preparation, methods, and lessons learned for an effective palliative simulation curriculum can be expanded upon by other pediatric training programs, and a more rigorous research program should be added to educational series.

Simulation-based education to improve emergency management skills in caregivers of tracheostomy patients.

INTRODUCTION: Children with tracheostomies are medically complex and may be discharged with limited and variably trained home nursing support. When faced with emergencies at home, caregivers must often take the lead role in management, and many lack experience with troubleshooting these emergencies prior to initial discharge. METHODS: A high-fidelity simulation-based tracheostomy education program was designed using a programmable mannequin (Gaumard HAL S3004 one-year-old pediatric simulator). At the conclusion of our standard education program, caregivers completed three simulation scenarios: desaturation, mucus plugging, and dislodgement. A trained simulation facilitator graded performance. A self-assessment tool was used to analyze comfort with emergency management at the beginning of training, before and after simulation. Caregivers rated confidence using a 10 cm visual analog scale. All participants completed a post-simulation debriefing session. RESULTS: 39 caregivers completed all three scenarios and returned pre- and post-simulation self-assessments. Mean scores from the caregiver self-assessments increased for all three scenarios, with mean increases of 9 mm for desaturation, 16 mm for mucus plugging, and 10 mm for decannulation. Two patterns of responses emerged: caregivers with progressive increase in confidence through training, and caregivers who initially rated confidence highly, and had confidence decrease as the complexity of true emergency management became apparent. All participants found the simulations to be realistic and helpful. DISCUSSION: High-fidelity simulation training allows for realistic exposure to trach-related emergencies. Many caregivers overestimate their ability to handle emergencies and gain important insight through simulation. IMPLICATIONS FOR PRACTICE: Identification of skills and knowledge gaps prior to discharge allows for targeted re-education in emergency management.

Rapid Cycle Deliberate Practice Versus Reflective Debriefing for Pediatric Septic Shock Training.

OBJECTIVES: Rapid cycle deliberate practice is a simulation training method that cycles between deliberate practice and directed feedback to create perfect practice; in contrast to reflective debriefing where learners are asked to reflect on their performance to create change. The aim of this study is to compare the impact of rapid cycle deliberate practice versus reflective debriefing training on resident application and retention of the pediatric sepsis algorithm. DESIGN: Prospective, randomized-control study. SETTING: A tertiary care university children's hospital simulation room, featuring a high-fidelity pediatric patient simulator. SUBJECTS: Forty-six upper-level pediatric residents. INTERVENTIONS: Simulation training using rapid cycle deliberate practice or reflective debriefing. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed with a quiz on core sepsis management topics. The application of knowledge was assessed with a sepsis management checklist during the simulated scenario. The residents were assessed before and after the intervention and again at a follow-up session, 3-4 months later, to evaluate retention. Both groups had similar pre-intervention scores. Post-intervention, the rapid cycle deliberate practice group had higher checklist scores (rapid cycle deliberate practice 18 points [interquartile range, 18-19] vs reflective debriefing 17 points [interquartile range, 15-18]; p < 0.001). Both groups had improved quiz scores. At follow-up, both groups continued to have higher scores compared with the pre-intervention evaluation, with the rapid cycle deliberate practice group having a greater change in checklist score from pre-intervention to follow-up (rapid cycle deliberate practice 5 points [interquartile range, 3.5-7] vs reflective debriefing 3 points [interquartile range, 1.5-4.5]; p = 0.019). Both groups reported improved confidence in diagnosing and managing septic shock. CONCLUSIONS: Both rapid cycle deliberate practice and reflective debriefing are effective in training pediatric residents to apply the sepsis algorithm and in improving their confidence in the management of septic shock. The rapid cycle deliberate practice method was superior immediately post-training; however, it is unclear if this advantage is maintained over time. Both methods should be considered for training residents.

Characterization of Myocardial Dysfunction in Fluid- and Catecholamine-Refractory Pediatric Septic Shock and Its Clinical Significance.

PURPOSE:: Myocardial dysfunction is a known complication in patients with pediatric septic shock (PSS); however, its clinical significance remains unclear. The purpose of this study was to characterize left ventricular (LV) and right ventricular (RV) dysfunction and their prevalence in patients with PSS using echocardiography (echo) and to investigate their associations with the severity of illness and clinical outcomes. METHODS:: Retrospective chart review between 2010 and 2015 from 2 tertiary care pediatric intensive care units. Study included 78 patients (mean age 9.3 ± 7 years) from birth up to 21 years who fulfilled criteria for fluid- and catecholamine-refractory septic shock. Echocardiographic parameters of systolic, diastolic, and global function were measured offline. They were correlated with admission Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction scores, vasoactive-inotrope score (VIS), ß-type natriuretic peptide (BNP), lactate, type of shock, duration of mechanical ventilation (MV), intensive care unit and hospital length of stay, and mortality. RESULTS:: Overall, 28-day mortality was 26%, and 88% patients required MV. Prevalence of LV dysfunction was 72% and RV dysfunction was 63%. LV systolic dysfunction (fractional shortening z score <-2) was significantly associated with PRISM III, VIS, and BNP. RV systolic dysfunction (tricuspid annular plane systolic excursion z score <-2) was significantly associated with cold shock. LV and RV diastolic dysfunction did not have any significant clinical associations. No echocardiographic measures were associated with mortality. CONCLUSION:: Myocardial dysfunction is highly prevalent in PSS but is not associated with mortality. LV systolic dysfunction is associated with a higher severity of illness, use of vasoactives, and BNP, whereas RV systolic dysfunction is associated with cold shock. Further studies are needed to determine the utility of echo in the bedside management of patients with PSS.

A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training.

INTRODUCTION: Medication administration events (MAEs) are a great concern to the healthcare industry, because they are both common and costly. Pediatric patients pose unique challenges to healthcare systems, particularly regarding the safety of medication administration. Our objectives were to improve adherence to best practices, decrease MAEs, and decrease cost related to error reduction rates by implementing a scenario-based simulation training program for frontline nursing staff in the general care units, emergency departments, and intensive care units within our institution. METHODS: Children's simulation center in conjunction with the medication safety workgroup developed a 2-hour target-specific simulation-based training. This quality initiative focused on implementation of a MAE bundle that included the following three elements: The Five Rights, MedZone, and Independent Double Check. Adherence to the use of bundle elements was monitored via bedside auditing for 18 months after the intervention. This audit was accomplished using an institution-wide MAE reporting system. The 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database and 2014 Children's Hospital Association, Pediatric Health Information System databases were used to estimate cost impact. RESULTS: A total of 1434 nurses from our intensive care units, emergency departments, and general care inpatient units participated in simulation training. Nursing adherence to the MAE bundle in the 18-month period after simulation increased by 33%, from January 2014 to June 2015. Medication administration event monitoring during the preintervention, intervention, and postintervention periods demonstrated a decrease in error rate from 2.5 events per month to 0.86 events per month This error reduction correlated to an estimated charge savings of $165,000 to $255,000 and a cost impact of $90,000 to $130,000 per year. CONCLUSIONS: Target-specific simulation-based training on a large scale has improved adherence with best practice guidelines and has led to a significant reduction in MAEs.