A simulation workshop to introduce coping skills.

BACKGROUND: Experiencing clinical catastrophes can result in long-lasting emotional and psychological impacts. In other fields, crisis simulation has been used to train professionals in coping skills. APPROACH: Our workshop combined a simulated case with a clinical debrief and expert-led teaching on coping skills. The '4Rs' mnemonic, Recognise, Reflect, Reframe and Reach-out, describes the key elements. This is grounded in social, cognitive and behavioural theories of stress and coping. EVALUATION: All 96 anesthesiology residents from one residency programme participated, in small groups, and a mixed methods analysis was used. The scenario was deemed stressful. The workshop introduced new techniques, with 72/87 (82.75%) reporting new coping skills in use at 1-month follow-up. For many residents, the descriptive language regarding their performance and abilities shifted from critical, negative self-talk to positive and team-focused immediately following the workshop. A striking finding from evaluations at all timepoints was that negative comments were typically self-referencing whereas positive ones referenced colleague support and the team. IMPLICATIONS: Combining stress exposure with formal exploration of emotional responses and coping skills teaching in this workshop was feasible, with benefits at 1-month follow-up. This laid the groundwork for a resilience curriculum and wider departmental interest in the topic of coping and stress responses.

Sequential Behavioral Analysis: A Novel Approach to Help Understand Clinical Decision-Making Patterns in Extended Reality Simulated Scenarios.

SUMMARY STATEMENT: Extended reality (XR)-based simulation training offers unique features that facilitate collection of dynamic behavioral data and increased immersion/realism while providing opportunities for training health care professionals on critical events that are difficult to recreate in real life. Sequential analysis can be used to summarize learning behaviors by discovering hidden learning patterns in terms of common learning or clinical decision-making sequences. This project describes the use of sequential analysis to examine differential patterns of clinical decision-making behaviors in observed XR scenarios, allowing for new insights when using XR as a method to train for critical events and to trace clinical decision making.

Intravenous ondansetron reduced nausea but not pruritus following intrathecal morphine in children: Interim results of a randomized, double-blinded, placebo-control trial.

STUDY OBJECTIVE: This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults. DESIGN: A double-blinded, randomized placebo-controlled trial. SETTING: Operating room and first 24 h postoperative inpatient stay at an academic children's hospital. PATIENTS: Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included. INTERVENTIONS: Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized. MEASUREMENTS: Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales. MAIN RESULTS: The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9]. CONCLUSIONS: This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.

Paediatric anaesthesiology education: simulation-based 'attending boot camp' for fellows shows feasibility and value in the early years of attendings' careers.

Background: Established simulation-based 'boot camps' utilise adult learning theory to engage and teach technical and non-technical skills to medical graduates transitioning into residency or fellowship. However, the transition from trainee to the attending role has not been well studied. The primary aim of this study was to design and execute a simulation-based educational day, exposing senior trainees in paediatric anaesthesia to commonly encountered challenges and teaching critical technical skills relevant to their new role. Secondary aims included assessment of its value and relevance in early years of graduated fellows' new careers as attendings. Methods: An 'attending boot camp' day comprised the following: two crisis simulations, an otolaryngologist-taught cadaver cricothyroidotomy laboratory, and a difficult conversations workshop. There was a debriefing after each section. Data were collected using end-of-day and early-career e-mail surveys for five consecutive fellow cohorts from 2016 to 2020. Results: Forty fellows participated; overall feedback was positive. The end-of-day surveys revealed planned changes in practice for 89% (25/28) of fellows, and 54% (15/28) highlighted communication skills as 'most beneficial'. Early-career follow-up surveys found 96% (23/24) identified increased confidence in skill acquisition because of the day; 79% (19/24) experienced scenarios in real life similar to those simulated. The qualitative analysis revealed four high-value themes: delegation, leadership, clinical skills, and difficult communication. Conclusions: The transition from senior trainee to attending physician remains under-researched. A tailored simulation-based 'attending boot camp' was feasible and valued and may be useful in bridging this transition. Participants identified leadership practice, life-saving technical skills, and difficult communication practice as valuable and relevant in their early careers.

Virtual reality simulation for critical pediatric airway management training.

BACKGROUND: Pediatric airway emergencies are relatively rare, but have potentially devastating consequences. Simulation based education is important in providing zero-risk management experience for these critical events. AIMS: The aim of the study was to assess usability and feasibility of combined interactive instructional videos and a novel Virtual Reality (VR) trainer for healthcare professionals and to evaluate the impact of this combination on learners' knowledge of critical airway events in children. METHODS: The study population included medical students, residents, faculty, and advanced practice nurses. Participants completed a short baseline knowledge pre-test of pediatric airway emergency management, followed by these consecutive interventions: (1) Interactive instructional pediatric airway videos and (2) VR trainer (HoloLens technology), simulating a pediatric critical airway event. Participants were randomized to manage anaphylaxis or foreign body aspiration. Finally, participants completed a second knowledge test (post-test) and a survey of their perceptions of the videos and VR trainer. RESULTS: Forty-one participants were included in the study. Overall, both interventions were well received. Positive perceptions included realism, interactivity, and active learning environment. Negative comments focused on video speed and the VR trainer learning curve. Participants reported preferences for future training of pediatric airway events to include videos and VR trainers, with or without didactic lectures. Most areas of knowledge showed slight to significant improvements following the interventions. Specifically, questions on pediatric anatomy, anaphylaxis, Heimlich maneuver, and foreign body removal showed the highest improvement in scores (P < 0.05). CONCLUSIONS: Interactive videos, in combination with a VR experience, provide promising zero-risk training for pediatric critical airway events. RELEVANCE FOR PATIENTS: Pediatric airway emergencies are relatively rare, but the potential consequences are devastating. VR is established as a valued mode of education with regard to medical emergency training. Multimedia informational and instructional formats result in greater understanding of information. Results from our intervention, combining an interactive video tutorial and a VR experience, show this was well received by a cross section of health-care providers. We demonstrated improved test scores in a pediatric airways quiz.

Pain outcomes in children who received intrathecal vs intravenous opioids for pain control following major urologic surgery: a retrospective review.

BACKGROUND: Intrathecal (IT) opioid administration has been associated with postoperative benefits including reduced pain and opioid use in children. However, the postoperative benefits and risks of IT opioid administration during major urologic surgery in children remain unclear. AIM: The aim of this study was to compare postoperative pain and adverse event outcomes among children who received IT vs intravenous (IV) opioids during major urologic surgery. METHODS: We reviewed the medical records of children 3-17 years of age who underwent ureteroneocystostomy or pyeloplasty between 2006 and 2012. Electronically captured anesthetic and surgical data, postanesthesia care recovery unit (PACU) and nursing flowsheets, and daily progress notes through hospital discharge were reviewed. Analgesic techniques (i.e., IT or IV patient/nurse controlled opioids), all analgesic drugs and doses were recorded. Outcome measures included pain scores, need for rescue analgesics, opioid-related adverse events, and their treatments. RESULTS: Seventy-seven children received IT opioids and 51 received IV opioids. More children in the IV group required rescue analgesics and had higher pain scores at PACU discharge. Children in the IV group required rescue opioids more frequently than the IT group from 0 to 8 h and 8 to 16 h after PACU discharge, but rates were similar by 16-24 h 70% of children in IT group transitioned directly to oral opioids. Seven IT placements were considered as failed due to early need for rescue opioids. Four (8%) of the IV group and seven (9%) of the IT group experienced oxygen desaturation. Two of these, both in IT group required naloxone and one was admitted to ICU for observation. The IT group experienced a higher incidence of pruritus, constipation and hypotension. CONCLUSION: We observed better postoperative pain control in children who received IT vs IV opioids for the first 16 h with no discernible difference thereafter. The intrathecal group experienced higher incidences of pruritus, constipation, and hypotension.