Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods.

Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations.

Understanding self-assessment as an informed process: residents' use of external information for self-assessment of performance in simulated resuscitations.

Self-directed learning requires self-assessment of learning needs and performance, a complex process that requires collecting and interpreting data from various sources. Learners' approaches to self-assessment likely vary depending on the learner and the context. The aim of this study was to gain insight into how learners process external information and apply their interpretation of this information to their self-assessment and learning during a structured educational activity. The study combined quantitative performance data with qualitative interview data. Pediatric residents led video-recorded simulated resuscitations and rated their crisis resource management skills on a validated 6-item instrument. Three independent observers rated the videos using the same instrument. During semi-structured interviews, each resident reviewed the video, rerated performance, discussed the self-assessment process, and interpreted feedback and observer scores. Transcripts were analyzed for themes. Sixteen residents participated. Residents' self-assessed scores ranged widely but usually fell within two points of the observers. They almost universally lowered their scores when self-assessing after the video review. Five major themes emerged from qualitative analysis of their interviews: (1) residents found self-assessment important and useful in certain contexts and conditions; (2) residents varied in their self-directed learning behaviors after the simulated resuscitation; (3) quantitative observer assessment had limited usefulness; (4) video review was difficult but useful; and (5) residents focused on their weaknesses and felt a need for constructive feedback to enhance learning. The residents in our study almost uniformly embraced the importance of self-assessment for all medical professionals. Even though video review had a negative impact on their self-assessment scores and was perceived as painful, residents saw this as the most useful aspect of the study exercises residents. They were less accepting of the quantitative assessment by observers. Residents explained their tendency to focus on weaknesses as a way to create an incentive for learning, demonstrating that self-assessment is closely linked to self-directed learning. How learners can use video review and external assessment most effectively to guide their self-directed learning deserves further study.

Validation of a self-efficacy instrument and its relationship to performance of crisis resource management skills.

Self-efficacy is thought to be important for resuscitation proficiency in that it influences the development of and access to the associated medical knowledge, procedural skills and crisis resource management (CRM) skills. Since performance assessment of CRM skills is challenging, self-efficacy is often used as a measure of competence in this area. While self-efficacy may influence performance, the true relationship between self-efficacy and performance in this setting has not been delineated. We developed an instrument to measure pediatric residents' self-efficacy in CRM skills and assessed its content validity, internal structure, and relationship to other variables. After administering the instrument to 125 pediatric residents, critical care fellows and faculty, we performed an exploratory factor analysis within a confirmatory factor analysis as well as a known group comparison. The analyses specified four factors that we defined as: situation awareness, team management, environment management, and decision making. Pediatric residents reported lower self-efficacy than fellows and faculty in each factor. We also examined the correlation between self-efficacy and performance scores for a subset of 30 residents who led video recorded simulated resuscitations and had their performances rated by three observers. We found a significant, positive correlation between residents' self-efficacy in situation awareness and environment management and their overall performance of CRM skills. Our findings suggest that in a specific context, self-efficacy as a form of self-assessment may be informative with regards to performance.