Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit.

OBJECTIVE: Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. DESIGN: Prospective, observational pilot study. SETTING: Single tertiary children's hospital pediatric intensive care unit. SUBJECTS: Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. INTERVENTIONS: A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. MEASUREMENTS AND MAIN RESULTS: For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd). CONCLUSIONS: It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

Enforced expression of Simian virus 40 large T-antigen leads to testicular germ cell tumors in zebrafish.

Testicular germ cell tumors (TGCTs) are the most common malignancy in young men. However, there are few in vivo animal models that have been developed to study this disease. We have used the pufferfish (fugu) lymphocyte-specific protein tyrosine kinase (flck) promoter, which has been shown to enforce high-level expression in the testes of transgenic mice, to express Simian virus 40 large T-antigen in zebrafish testes. Zebrafish that express T-antigen develop TGCTs after a long latency of >1 year. Although overt TGCTs are only evident in 20% of the fish, occult TGCTs can be detected in 90% of the transgenic fish by 36 month of age. The TGCTs resemble the human disease in terms of morphology and gene expression pattern, and can be transplanted to healthy wild-type recipient fish. In addition, enforced expression of the zebrafish stem cell leukemia (scl) gene in the zebrafish testes also generated TGCTs in transgenic fish. These results demonstrate the feasibility of studying TGCTs in a model organism.