Performance of anesthesia residents during a simulated prone ventricular fibrillation arrest in an anesthetized pediatric patient.

BACKGROUND: Exposure to rare pediatric anesthesia emergencies varies depending on the residency program. Simulation can provide increased exposure to these rare events, improve performance of residents, and also aid in standardizing the curriculum. OBJECTIVE: The purpose of this study was to evaluate time to recognize and treat ventricular fibrillation in a pediatric prone patient and to expose learners to the difficulties of managing emergencies in prone patients. METHODS: Standardized simulation sessions were conducted monthly for 13 months with groups of 1-2 residents in each simulation. The scenario involved a prone patient undergoing posterior spinal fusion. Ventricular fibrillation occurred three minutes into the case. Sessions were viewed by simulation staff, and time to events was recorded. A scripted debriefing followed each case. Evaluations were completed by each participant. RESULTS: The average time to start chest compressions was 77 s, and the average time in recognizing ventricular fibrillation was 76 s. No group performed chest compressions while prone. Only one group defibrillated in the prone position. Participants average time to request defibrillation was 108 s. While nine of 13 groups (69%) ordered an arterial blood gas, only five recognized hyperkalemia, and only four groups gave calcium. CONCLUSIONS: Anesthesia residents need additional training in recognizing and treating operative ventricular fibrillation, especially in prone patients and rarely encountered etiologies such as hyperkalemia. Training in the treatment of uncommon pediatric emergencies should be a focal point in anesthesia residency programs.

Randomized trial comparing two mass casualty triage systems (JumpSTART versus SALT) in a pediatric simulated mass casualty event.

PURPOSE: Several field triage systems have been developed to rapidly sort patients following a mass casualty incident (MCI). JumpSTART (Simple Triage and Rapid Transport) is a pediatric-specific MCI triage system. SALT (Sort, Assess, Lifesaving interventions, Treat/Transport) has been proposed as a new national standard for MCI triage for both adult and pediatric patients, but it has not been tested in a pediatric population. This pilot study hypothesizes that SALT is at least as good as JumpSTART in triage accuracy, speed, and ease of use in a simulated pediatric MCI. METHODS: Paramedics were invited and randomly assigned to either SALT or JumpSTART study groups. Following randomization, subjects viewed a 15-minute PowerPoint lecture on either JumpSTART or SALT. Subjects were provided with a triage algorithm card for reference and were asked to assign triage categories to 10 pediatric patients in a simulated building collapse. The scenario consisted of 4 children in moulage and 6 high-fidelity pediatric simulators. Injuries and triage categories were based on a previously published MCI scenario. One investigator followed each subject to record time and triage assignment. All subjects completed a post-test survey and structured interview following the simulated disaster. RESULTS: Forty-three paramedics were enrolled. Seventeen were assigned to the SALT group with an overall triage accuracy of 66% ±15%, an overtriage mean rate of 22 ± 16%, and an undertriage rate of 10 ± 9%. Twenty-six participants were assigned to the JumpSTART group with an overall accuracy of 66 ± 12%, an overtriage mean of 23 ±16%, and an undertriage rate of 11.2 ± 11%. Ease of use was not statistically different between the two systems (median Likert value of both systems = 2, p = 0.39) Time to triage per patient was statistically faster in the JumpSTART group (SALT = 34 ± 23 seconds, JumpSTART = 26 ± 19 seconds, p = 0.02). Both systems were prone to cognitive and affective error. CONCLUSION: SALT appears to be at least as good as JumpSTART in overall triage accuracy, overtriage, or undertriage rates in a simulated pediatric MCI. Both systems were considered easy to use. However, JumpSTART was 8 seconds faster per patient in time taken to assign triage designations.

Transfer of simulated lumbar puncture training to the clinical setting.

OBJECTIVE: To show that with a combination of evidence-based didactic and hands-on skill demonstration, pediatric interns will be able to correctly perform lumbar punctures (LPs) on neonates in the actual clinical setting. METHODS: Twenty-three pediatric and internal medicine/pediatric first year residents attended a 1-hour course during their orientation. The course consisted of an evidence-based presentation, reviewing anatomy, indications, complications, and techniques for performing LPs, including a video presentation, followed by hands-on practice of LPs. All interns were anonymously surveyed preintervention and postintervention. The survey results were compared for each learner. After the intervention, interns were individually assessed by a single investigator using a standardized checklist during an LP of an actual pediatric patient during their first year of residency. RESULTS: Pretest and posttest knowledge improved by approximately 12% (P < 0.05). Preintervention confidence and experience were low among learners. Twenty-one of 23 interns completed a follow-up assessment of an LP on an actual pediatric patient. The average on the assessment was 9.7 ± 1.1 of 11 (88% ± 10%). The average number of LP attempts was 1.4 ± 0.5. The steps most frequently missed were preparing the supplies and performing the LP with the bevel of the needle parallel to the spinal ligament, with only 48% of interns performing each of these steps correctly. CONCLUSIONS: A task trainer-based course improved the confidence and knowledge about an important pediatric procedure. This confidence and knowledge can translate to actual clinical practice. Further investigations are necessary to support this knowledge and skill translation.

High-fidelity simulation training for sleep technologists in a pediatric sleep disorders center.

STUDY OBJECTIVES: Severe events of respiratory distress can be life threatening. Although rare in some outpatient settings, effective recognition and management are essential to improving outcomes. The value of high-fidelity simulation has not been assessed for sleep technologists (STs). We hypothesized that knowledge of and comfort level in managing emergent pediatric respiratory events would improve with this innovative method. METHODS: We designed a course that utilized high-fidelity human patient simulators (HPS) and that focused on rapid pediatric assessment of young children in the first 5 minutes of an emergency. We assessed knowledge of and comfort with critical emergencies that STs may encounter in a pediatric sleep center utilizing a pre/post-test study design. RESULTS: Ten STs enrolled in the study, and scores from the pre- and posttest were compared utilizing a paired samples t-test. Mean participant age was 42 ± 11 years, with average of 9.3 ± 3.3 years of ST experience but minimal experience in managing an actual emergency. Average pretest score was 54% ± 17% correct and improved to 69% ± 16% after the educational intervention (p < 0.05). Participant ratings indicated the course was a well-received, innovative educational methodology. CONCLUSIONS: A simulation course focusing on respiratory emergencies requiring basic life support skills during the first 5 min of distress can significantly improve the knowledge of STs. Simulation may provide a highly useful methodology for training STs in the management of rare life-threatening events.

Pediatric intensive care simulation course: a new paradigm in teaching.

OBJECTIVE: True pediatric emergencies are rare. Because resident work hours are restricted and national attention turns toward patient safety, teaching methods to improve physician performance and patient care are vital. We hypothesize that a critical-care simulation course will improve resident confidence and performance in critical-care situations. INTERVENTIONS: We developed a monthly pediatric intensive care unit simulation course for second-year pediatric residents that consisted of weekly 1-hour sessions during both of the residents' month-long pediatric intensive care unit rotations. All scenarios used high-fidelity pediatric simulators and immediate videotape-assisted debriefing sessions. In addition, simulated intraosseous line insertion and endotracheal intubations were also performed. RESULTS: All residents improved their comfort level and confidence in performing individual key resuscitation tasks. The largest improvements were seen with their perceived ability to intubate children and place intraosseous lines. Both of these skills improved from baseline and compared to third-year-resident controls who had pediatric intensive care unit rotations but no simulations (P = .05 and P = .07, respectively). Videotape reviews showed only 54% ± 12% of skills from a scenario checklist performed correctly. CONCLUSIONS: Our simulation-based pediatric intensive care unit training course improves second-year pediatric residents' comfort level but not performance during codes, as well as their perceived intubation and intraosseous ability. Videotape reviews show discordance between objective performance and self-assessment. Further work is necessary to elucidate the reasons for this difference as well as the appropriate role for simulation in the new graduate medical education climate, and to create new teaching modalities to improve resident performance.

Use of simulation to enhance learning in a pediatric elective.

OBJECTIVES: To assess the impact on learning of adding a pediatric human patient simulation to a pharmacy course. DESIGN: Pharmacy students enrolled in a pediatric elective participated in 1 inpatient and 1 outpatient scenario using a pediatric patient simulator. Immediately following each case, reflective debriefing occurred. ASSESSMENT: Forty-two students participated in the simulation activity over 2 academic years. A pretest and posttest study design was used, with average scores 4.1 + or - 1.2 out of 9 on pretest and average 7.0 + or - 1.5 out of 9 on posttest (p < 0.0001). Ninety-five percent (40/42) of students' scores improved. Students felt the learning experiences were positive and realistic. CONCLUSIONS: Pharmacy students' knowledge and application skills improved through use of pediatric simulation exercises.

Initiation of a pediatric mock code program at a children's hospital.

BACKGROUND: Pediatric cardiopulmonary arrests are rare. Mock codes were instituted to bridge the gap between opportunity and reality. AIM: The goal was to improve medical caregivers' skills in pediatric resuscitation. METHODS: All pediatric and internal medicine/pediatric (med/peds) residents were anonymously surveyed pre- and post-intervention about confidence level about codes and code skills. Twenty mock codes were conducted during the 1 year intervention period. Statistical comparisons were made between each resident pre- and post-survey, graduating third-year residents (PGY3s) prior to intervention versus PGY3s with mock codes and pediatric versus med/peds residents. RESULTS: All residents significantly improved in their perception of overall skill level during the study (p < 0.0001). PGY3s were significantly more confident in their skills than PGY2s or PGY1s and PGY2s were significantly more confident than PGY1s both pre- and post-mock codes (p < 0.0001). Med/peds residents were significantly more confident in their skills than pediatric residents both pre- (p = 0.041) and post-intervention (p = 0.016). The two skills with the lowest score post-intervention were the ability to place an interosseous line and the ability to manage cardiac dysrhythmias. CONCLUSIONS: Pediatric mock codes can improve resident confidence and self-assessment of their resuscitation skills. Data from surveys such as this can be used to design future skill-based educational initiatives.