The Effect of a Plastic Barrier Drape on Resuscitation Performance and Provider Contamination: A Randomized Controlled Simulation-Based Pilot Trial.

BACKGROUND: Patient barriers to protect health care workers from COVID-19 exposure have been studied for airway management. Few are tested for cardiopulmonary resuscitation (CPR). We sought to determine whether a plastic drape barrier affects resuscitation performance and contamination risks for a simulated cardiopulmonary arrest scenario. METHODS: This pilot trial randomized in-hospital resuscitation teams of 4 to 6 participants to a plastic drape or without a drape in an in situ cardiopulmonary arrest simulation. The mannequin's airway emanated simulated virus particles (GloGerm, Moab, UT), detectable through UV light. Primary outcomes included airway management and CPR quality measures. Secondary outcomes included visible contamination on personal protective equipment (PPE). We used the Non-Technical Skills (NO-TECHS) instrument to measure perceived team performance and the NASA Task Load Index (NASA-TLX) to measure individual workload. Outcome variables were analyzed using an analysis of covariance (ANCOVA) with participant number as a covariate. RESULTS: Seven teams were allocated to the intervention (plastic drape) group and 7 to the control. Intubation and ventilation performance (η 2 = 0.09, P > 0.3) and chest compression quality (η 2 = 0.03-0.19, P > 0.14) were not affected by the plastic drape. However, mean contaminated PPE per person decreased with the drape (2.8 ± 0.3 vs. 3.7 ± 0.3, partial η 2 = 0.29, P = 0.05). No differences in perceived workload nor team performance were noted ( P > 0.09). CONCLUSIONS: In this pilot study, the use of a plastic drape barrier seems not to affect resuscitation performance on simulated cardiopulmonary arrest but decreases health care worker contamination risk. Further implementation trials could characterize the true risk reduction and any effect on resuscitation outcomes.

Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter.

Introduction: A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. Methods: This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Results: Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Conclusions: The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.

Validation of a 3-Dimensional-Printed Infant Tibia for Intraosseous Needle Insertion Training.

INTRODUCTION: Current bone models used for pediatric intraosseous (IO) placement training are expensive or lack anatomic and/or functional fidelity. This technical report describes the development and validation of a 3-dimensional printed (3DP) tibia from a pediatric lower extremity computed tomography scan for IO procedural training. METHODS: Multiple 3DP tibia models were printed using a dual-extrusion fused-filament fabrication printer. Models underwent iterative optimization until 2 final models, one of polypropylene (3DP clear) and the other of polylactic acid/polypropylene (3DP white), were selected. Using an exploratory sequential mixed-methods design, a novel IO bone model assessment tool was generated. Physicians then used the assessment tool to evaluate and compare common IO bone models to the novel 3DP models during IO needle insertion. RESULTS: Thirty physicians evaluated the provided pediatric IO bone models. Compared with a chicken bone as a reference, the 3DP white bone had statistically significantly higher mean scores of anatomy, heft, sense of being anchored in the bone, quality of bone resistance, and "give" when interfaced with an IO needle. Twenty-two of the 30 participants ranked the 3DP white bone as either 1st or 2nd in terms of ranked preference of pediatric IO bone model. A 3DP white bone costs $1.10 to make. CONCLUSIONS: The 3DP IO tibia models created from real-life computed tomography images have high degrees of anatomic and functional realism. These IO training models are easily replicable, highly appraised, and can be printed at a fraction of the cost of commercially available plastic models.

Development of a Mannequin for Simulation-Based Trials Involving Respiratory Viral Spread During Respiratory Arrest and Cardiopulmonary Arrest Scenarios.

During the coronavirus disease 2019 (COVID-19) pandemic, mannequin models have been developed to mimic viral spread using fluorescent particles. These models use contraptions such as a spray gun or an exploding latex balloon to emanate a sudden acceleration of particles, simulating a "cough" reflex. No models have been developed to mimic passive aerosolization of viral particles during a cardiopulmonary arrest simulation. Our novel approach to aerosolization of simulated viral spread allows for a continuous flow of particles, which allows us to maintain components of high-fidelity team-based simulations. Our simulated model emanated GloGerm (Moab, UT) from the respiratory tract using a continuous nebulization chamber. Uniquely, the construction of our apparatus allowed for the ability to perform full, simulated cardiopulmonary resuscitation scenarios (such as chest compressions, bag-mask ventilation, and endotracheal intubation) on a high-fidelity mannequin while visualizing potential contamination spread at the conclusion of the simulation. Positive feedback from users included the ability to visualize particulate contamination after cardiopulmonary resuscitations in the context of personal protective equipment usage and roles in resuscitation (i.e. physician, respiratory therapist, nurse). Negative criticism towards the simulation included the lack of certain high-fidelity feedback markers of the mannequin (auscultating breath sounds and checking pulses) due to the construction of the particle aerosolization mechanism.

The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial.

OBJECTIVES: Rudeness exposure has been shown to inhibit diagnostic performance. The effects of rudeness on challenging a handed-off diagnostic error has not been studied. METHODS: This was a randomized controlled study of attending, fellow, and resident physicians in a tertiary care pediatric ICU. Participants underwent a standardized simulation that started with the wrong diagnosis in hand-off. The hand-off was randomized to neutral vs. rude. Participants were not informed of the randomization nor diagnostic error prior to the simulation. Perspective taking questionnaires were administrated for each participant. Primary outcome was challenging diagnostic error post-simulation. Secondary outcomes included rate and frequency of diagnostic error challenge during simulation. RESULTS: Among 41 simulations (16 residents, 14 fellows, and 11 attendings), the neutral group challenged the diagnostic error more than the rude group (neutral: 71%, rude: 55%, p=0.28). The magnitude of this trend was larger among resident physicians only, although not statistically significant (neutral: 50%, rude: 12.5%, p=0.11). Experience was associated with a higher percentage of challenging diagnostic error (residents: 31%, fellows: 86%, attendings: 82%, p=0.003). Experienced physicians were faster to challenge diagnostic error (p<0.0003), and experience was associated with a greater frequency of diagnostic error challenges (p<0.0001). High perspective taking scores were also associated with 1.63 times more diagnostic error challenges (p=0.007). CONCLUSIONS: Experience was strongly associated with likelihood to challenge diagnostic error. Rudeness may disproportionally hinder diagnostic performance among less experienced physicians. Perspective taking merits further research in possibly reducing diagnostic error momentum.

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation.

PURPOSE: Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients. METHODS: An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation. RESULTS: Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers. CONCLUSIONS: Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence. LEVEL OF EVIDENCE: II, Prospective cohort.

Gamification in Action: Theoretical and Practical Considerations for Medical Educators.

Gamification involves the application of game design elements to traditionally nongame contexts. It is increasingly being used as an adjunct to traditional teaching strategies in medical education to engage the millennial learner and enhance adult learning. The extant literature has focused on determining whether the implementation of gamification results in better learning outcomes, leading to a dearth of research examining its theoretical underpinnings within the medical education context. The authors define gamification, explore how gamification works within the medical education context using self-determination theory as an explanatory mechanism for enhanced engagement and motivation, and discuss common roadblocks and challenges to implementing gamification.Although previous gamification research has largely focused on determining whether implementation of gamification in medical education leads to better learning outcomes, the authors recommend that future research should explore how and under what conditions gamification is likely to be effective. Selective, purposeful gamification that aligns with learning goals has the potential to increase learner motivation and engagement and, ultimately, learning. In line with self-determination theory, game design elements can be used to enhance learners' feelings of relatedness, autonomy, and competence to foster learners' intrinsic motivation. Poorly applied game design elements, however, may undermine these basic psychological needs by the overjustification effect or through negative effects of competition. Educators must, therefore, clearly understand the benefits and pitfalls of gamification in curricular design, take a thoughtful approach when integrating game design elements, and consider the types of learners and overarching learning objectives.

Self-assessment of team performance using T-NOTECHS in simulated pediatric trauma resuscitation is not consistent with expert assessment.

BACKGROUND: The Trauma NOn-TECHnical Skills (T-NOTECHS) tool has been used to assess teamwork in trauma resuscitation, but its reliability and validity for self-assessment is unknown. Our purpose was to determine the reliability and validity of self-administered T-NOTECHS in pediatric trauma resuscitation. METHODS: Simulated in situ resuscitations were evaluated using T-NOTECHS in real time by experts and immediately afterwards by team members. Reliability was analyzed with linear-weighted kappa and intra-class correlation. T-NOTECHS scores were compared between expert (gold-standard) and self-assessment. RESULTS: Fifteen simulations were examined. T-NOTECHS scores were similar between self- and expert assessment for leadership. Self-assessment scores were higher than expert for the other domains and total composite score. Inter-rater reliability for total score was similar between the two groups, but differences were observed in the domains. CONCLUSIONS: Self-assessment is not interchangeable with expert rating when using T-NOTECHS. Future studies need to determine how self-assessment can be best utilized. LEVEL OF EVIDENCE: Studies of diagnostic accuracy - Level 2.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date. METHODS: We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use. RESULTS: Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7-12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5-5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2-6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%). DISCUSSION: Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Qualitative assessment of simulation-based training for pediatric trauma resuscitation.

BACKGROUND: Effective teamwork is critical in the trauma bay, although there is a lack of consensus related to optimal training for these skills. We implemented in situ trauma simulations with debriefing as a possible training methodology to improve team-oriented skills. METHODS: Focus groups were conducted with multidisciplinary clinicians who respond to trauma activations. The focus group questions were intended to elicit discussion on the clinicians' experiences during trauma activations and simulations with an emphasis on confidence, leadership, cooperation, communication, and opportunities for improvement. Thematic content analysis was conducted using Atlas.ti analytical software. RESULTS: Ten focus groups were held with a total of 55 clinicians. Qualitative analysis of focus group feedback revealed the following selected themes: characteristics of a strong leader during a trauma, factors impacting trauma team members' confidence, and effective communication as a key component during trauma response. Participants recommended continued simulations to enhance trauma team trust and efficiency. CONCLUSION: Clinicians responding to pediatric trauma resuscitations valued the practice they received during trauma simulations and supported the continuation of the simulations to improve trauma activation teamwork and communication. Findings will inform the development of future simulation-based training programs to improve teamwork, confidence, and communication between trauma team members.

The effect of multimedia replacing text in resident clinical decision-making assessment.

Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p2  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p2  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in CDMS, particularly in less experienced clinicians.

Glucose variability and survival in critically ill children: allostasis or harm?

OBJECTIVES: To assess whether individual blood glucose variability in critically ill children is associated with increased mortality and to define the temporal patterns of blood glucose variability during critical illness in children. DESIGN: Retrospective cohort study. SETTING: A 20-bed pediatric intensive care unit in a children's hospital. PATIENTS: Patients aged 0-20 yrs and with at least 12 blood glucose measurements taken within the first 72 hrs of pediatric intensive care unit admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 101 eligible patients had 3,144 measured blood glucose concentrations with 16% mortality. Nonsurvivors had higher median blood glucose concentrations (129 mg/dL vs. 118 mg/dL, p < .01), more hyperglycemia (blood glucose >200 mg/dL) (88% vs. 59%, p < .05), and more hypoglycemia (blood glucose <60 mg/dL) (56% vs. 15%, p < .01) than survivors. The mean blood glucose range (257 mg/dL vs. 185 mg/dL, p < .01) and the blood glucose variability (63 mg/dL vs. 45 mg/dL, p = .02) were greater in nonsurvivors compared with survivors. Blood glucose variability tertiles were proportionately associated with increasing mortality: 6% vs. 15% vs. 27% (p = .07). Compared with survivors, daily blood glucose variability was significantly higher in nonsurvivors during the first 48 hrs of admission and after 1 wk of admission. After controlling for confounders, individual blood glucose variability was associated with higher pediatric intensive care unit mortality for each mg/dL of blood glucose concentration (adjusted odds ratio, 1.03; 95% confidence interval, 1.01-1.05). CONCLUSIONS: Glucose variability is common in critically ill children and is associated with increased mortality. Whereas early alterations in blood glucose may represent allostasis, later fluctuations in blood glucose may represent an alteration of autoregulation with resulting higher mortality. Control of variability may need to be incorporated into glycemic control regimens.

Prospective detection of hyperglycemia in critically ill children using continuous glucose monitoring.

OBJECTIVE: To evaluate the extent of hyperglycemia in nondiabetic children admitted to a pediatric intensive care unit using an interstitial continuous glucose monitor, and to compare the ability of this interstitial continuous glucose monitoring system to detect hyperglycemia with that of intermittent laboratory monitoring. DESIGN: Prospective observational study. SETTING: Ten-bed pediatric intensive care unit in an academic referral medical center in western Massachusetts. PATIENTS: A convenience sample of 20 nondiabetic children, aged 1-18, anticipated to require intensive care >2 days. INTERVENTIONS: Placement of a subcutaneous continuous glucose monitor for 72 hrs with a subsequent second sensor placed if the patient and family agreed. Glucose levels were compared with laboratory glucose values. MEASUREMENTS AND MAIN RESULTS: Elevated glucose levels were revealed by 16,337 sensor glucose readings over a mean of 68 +/- 5.2 hrs per patient. Forty-three percent of readings were >125 mg/dL (6.9 mmol/L), 27.2% were >140 mg/dL (7.8 mmol/L), and 4.0% were >200 mg/dL (11.1 mmol/L). Laboratory glucose measurements demonstrated hyperglycemia less frequently and missed significant periods of hyperglycemia. CONCLUSIONS: Significant hyperglycemia is present in pediatric intensive care patients and may be underestimated by intermittent laboratory monitoring.