24 Original Article
Compliance with Guidelines Recommending the Use of Simulation for Neonatal and Infant Resuscitation Training in Austria
Authors
L. P. Mileder1, 2, B. Urlesberger2, J. Schwindt3, B. Simma4, G. M. Schmölzer2, 5, 6
Affiliations
Affiliation addresses are listed at the end of the article
Key words ▶ newborn ● ▶ infant ● ▶ resuscitation ● ▶ education ● ▶ simulation ●
Abstract
Zusammenfassung
Background: Current international resuscitation guidelines recommend simulation for the training of neonatal and infant resuscitation. We aimed at assessing compliance rates with these recommendations in Austria. Method: We performed a national questionnaire survey among 31 neonatal institutions in Austria. Results: 25 questionnaires (80.6 %) were analyzed. 22/25 institutions (88 %) used simulation as an instructional modality. 8 institutions (32 %) had access to medical simulation centers, with 6/8 being used for neonatal and infant resuscitation training. Simulation equipment was available at 17/25 institutions (68 %), with a median of 1 part-task trainer (0–2), 2 low-fidelity resuscitation mannequins (0–10), and 0 high-fidelity patient simulators (0–7). Resuscitation training frequency varied widely, ranging from one training per month to one training per year. 5 simulation centers utilized interdisciplinary resuscitation training with other medical specialties and team training including physicians and nursing staff. Of the 17 institutions with simulation equipment at their disposal, 8 (47.1 %) carried out interdisciplinary training and 13 (76.5 %) performed teamoriented training sessions. Discussion/Conclusion: The majority of surveyed institutions adopted simulation for neonatal and infant resuscitation training according to current guidelines and had simulation equipment at their disposal. However, educational practice varied widely, especially in regard to training frequency. Therefore, we suggest a national consensus agreement on best practices in simulation-based neonatal and infant resuscitation training.
Hintergrund: Aktuelle internationale Reanimationsrichtlinien empfehlen die Nutzung von Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung. Wir untersuchten die Umsetzung dieser Empfehlungen in Österreich. Methoden: Wir führten eine nationale Umfrage mittels Fragebögen an 31 neonatologischen Abteilungen in Österreich durch. Ergebnisse: 25 Fragebögen (80,6 %) wurden ausgewertet. 22/25 Institutionen (88 %) nutzten Simulation als Ausbildungsmethode. 8 Institutionen (32 %) hatten Zugang zu einem medizinischen Simulationszentrum, wovon 6 für Neugeborenenund Säuglingsreanimationsausbildung verwendet wurden. Simulationsmaterial war an 17/25 Institutionen (68 %) verfügbar, mit einem Median von 1 Einzelfertigkeitentrainer (0–2), 2 Low-fidelity-Simulatoren (0–10) und 0 High-fidelity-Patientensimulatoren (0–7). Die Trainingsfrequenzen zeigten eine ausgeprägte Variabilität und reichten von einem Training im Monat zu einem Training im Jahr. 5 Simulationszentren hielten interdisziplinäre Reanimationstrainings mit anderen Fachrichtungen und Teamtrainings von Ärzten und Pflegepersonal ab. Von den 17 Institutionen mit eigenem Simulationsmaterial veranstalteten 8 (47,1 %) interdisziplinäre Trainings und 13 (76,5 %) teamorientierte Trainings. Diskussion/Schlussfolgerung: Die Mehrheit der befragten Institutionen nutzte Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung gemäß aktuellen Richtlinien und verfügte über eigenes Simulationsmaterial. Die Umsetzung war jedoch sehr heterogen, insbesondere in Bezug auf die Trainingshäufigkeit. Wir empfehlen daher die Erstellung eines nationalen Konsensuspapiers zur Durchführung simulationsbasierter Ausbildung in der Neugeborenenund Säuglingsreanimation.
Schlüsselwörter ▶ Neugeborenes ● ▶ Säugling ● ▶ Reanimation ● ▶ Ausbildung ● ▶ Simulation ●
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1361106 Published online: January 16, 2014 Klin Padiatr 2014; 226: 24–28 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Lukas Peter Mileder Department of Pediatrics Division of Neonatology Medical University of Graz Auenbruggerplatz 38/1 8036 Graz Austria Tel.: + 43/699/11751 318 Fax: + 43/316/38513 953 [email protected]
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Mileder LP et al. Compliance with Guidelines Recommending … Klin Padiatr 2014; 226: 24–28
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Die Umsetzung von Empfehlungen zur Nutzung von Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung in Österreich
Original Article 25 Abbreviations
Table 1 Survey results.
▼
Number of institutions (n)
European Paediatric Life Support Newborn Life Support Neonatal Resuscitation Program Simulation-based medical education
Questionnaires analyzed
Background
▼
The Joint Commission on Accreditation of Healthcare Organizations, reporting on preventing infant death and injury during delivery, highlighted that failures in team communication account for more than two thirds of perinatal mortality and morbidity [14]. The report suggested using team training to improve communication and teamwork, and to conduct clinical drills to assess staff performance. Accordingly, current resuscitation guidelines recommend implementing simulation as an educational method for neonatal and infant resuscitation training [26, 28]. Simulation is “an education technique that allows interactive, and at time immersive, activity by recreating all or part of a clinical experience” [25]. Although verbal role playing and the use of part-task trainers for technical skills practice represent some form of simulation training, the terms ‘simulation-based training’ or ‘simulation-based medical education’ (SBME) usually describe the utilization of human actors and realistic, fully interactive patient simulators [12]. SBME offers numerous advantages, all of whom are critical when training healthcare professionals: i) controlled and risk-free learning, ii) repetitive deliberate practice, iii) customizability of training experiences to individual needs, and iv) objective assessment of and feedback on trainees’ performance [17, 25, 27]. Neonatal and infant resuscitation are high acuity, low occurrence events, which – although arising infrequently – still require high levels of cognitive and technical competency as well as mental preparedness [7]. Such events lend themselves well to simulationbased training [12], and SBME has been identified as “a highly effective instructional strategy for the acquisition and retention of skills requisite to competent performance in dynamic, high-pressure, high-consequence environments” such as delivery rooms [1].
Low- vs. high-fidelity simulation The term ‘fidelity’ refers to the degree to which a simulated experience replicates reality [9]. The simulator’s technical capability, environmental fidelity and the training’s psychological fidelity contribute to the overall fidelity of a simulation and should be adapted according to respective learning objectives [9]. Although both high- and low-fidelity simulation result in consistent performance improvement [21], a dose-response-like relationship between the numbers of practice hours and standardized learning outcomes has been described only for highfidelity simulator training [18]. The aim of this study was i) to assess the current availability and ii) the application of simulation-based neonatal and infant resuscitation training in pediatric hospitals in Austria.
Methods
▼
We performed a national questionnaire survey. The questionnaire (Appendix online) consisted of both open and closed
Resuscitation training methodologies: – supervised clinical practice – simulation-based training – theoretical education – NLS/EPLS courses Clinical skills/medical simulation center access: – availability at level II vs. level III centers – neonatal/infant resuscitation training – interdisciplinary training/team training Available simulation equipment: – training of medical staff – training of nursing staff – training at clinical locations – training in lecture halls and seminar rooms – team training – interdisciplinary training
n = 25/31 (80.6 %) 25/25 (100 %) 22/25 (88 %) 22/25 (88 %) 20/25 (80 %) 8/25 (32 %) 3/17 vs. 5/8* 6/8 (75 %) 5/8 (62.5 %) 17/25 (68 %) 17/17 (100 %) 15/17 (88.2 %) 12/17 (70.6 %) 10/17 (58.8 %) 13/17 (76.5 %) 8/17 (47.1 %)
NLS: Newborn Life Support; EPLS: European Paediatric Life Support; * p < 0.05
questions and focused on 3 major categories: i) demographic data of institutions (e. g. level of care, number of births per year), ii) training methodologies for residents and fellows, and availability of simulation equipment at university, hospital or department level (e. g. low-fidelity mannequins, high-fidelity patient simulators), and iii) utilization of simulation equipment (e. g. training frequency, interdisciplinary and team training). Space was provided for comments. In December 2012, the questionnaire was sent to consultant neonatologists at 31 level II and III neonatal centers in Austria, all with teaching responsibilities in neonatal care. In Austria, level III hospitals represent tertiary care centers (maximum medical care provided). The questionnaire was sent by e-mail with a covering letter describing the aim of the study, the intent to analyze and publish provided data, and names and e-mail addresses of involved researchers. Questionnaires could be answered electronically or printed, completed by hand, and returned by fax. If not returned after 8 weeks, a telephone call was made and the questionnaire administered a second time. The study period lasted from December 2012 to April 2013. Analyses consisted of frequency analysis (quantitative and qualitative data) and descriptive statistics. Percentages were calculated for categorical variables and means ( ± standard deviation) or median (range) for continuous data. We used Fisher’s exact test for categorical variables and Student’s t-test for independent samples to compare continuous variables. A p-value of less than 0.05 was deemed statistically significant. Statistical analysis was performed using IBM® SPSS Statistics, Version 20.
Results
▼
A total number of 26/31 questionnaires (83.9 %) were returned. However, one questionnaire was excluded due to missing pages, which left 25/31 questionnaires (80.6 %) for analysis. Selected ▶ Table 1. results are summarized in ● All 25 institutions reported neonatal and infant resuscitation training for pediatric and neonatal trainees through supervised clinical practice. In addition, 22/25 institutions (88 %) used SBME
Mileder LP et al. Compliance with Guidelines Recommending … Klin Padiatr 2014; 226: 24–28
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EPLS NLS NRP SBME
26 Original Article
Low- vs. high-fidelity simulation Overall, 8/25 institutions (32 %) had access to a clinical skills or medical simulation center, with significantly higher numbers of simulation centers available at level III (n = 5/8) compared to level II institutions (n = 3/17; p < 0.05). The most common purpose of these facilities was postgraduate neonatal and infant resuscitation training (n = 6/8). Simulation equipment was directly available at 17/25 institutions (68 %), which was evenly distributed between secondary and tertiary pediatric centers. Each institution had a median number of 1 part-task trainer (0–2), 2 low-fidelity resuscitation mannequins (0–10), and 0 high-fidelity patient simulators (0–7) available. The equipment was used for the training of medical staff in all 17 institutions, for nursing staff in 15/17 institutions (88.2 %), and for undergraduate medical students in 5/17 institutions (29.4 %). Resuscitation training was mainly carried out at clinical locations (e. g. hospital ward, intensive care unit, delivery room; n = 12/17) and/or in lecture halls and seminar rooms (n = 10/17). Institutions without simulation equipment at their disposal (8/25 institutions; 32 %) were asked to specify reasons. Availability of a simulation center and financial restrictions were named 5 times each. One institution made use of external simulation training, and another institution reported to lease simulation equipment biannually for training purposes. No institution acknowledged preferring non-simulation-based education.
physicians of other medical specialties and 13/17 (76.5 %) performed team training of pediatricians and nursing staff.
Discussion
▼
If utilized effectively, SBME is a powerful instructional methodology that has been recommended by neonatal and infant resuscitation guidelines [26, 28]. The aim of this study was to investigate the compliance with these recommendations in Austria. Almost all surveyed institutions (88 %) adopted simulation for resuscitation training as recommended by current guidelines. Hands-on training in the real healthcare environment, theoretical instruction, and NLS/EPLS courses were also utilized for resuscitation training. No institution was utilizing virtual training methodologies, although e-learning has the potential to improve both pediatric advanced life support knowledge and skills [22].
Low- vs. high-fidelity simulation
Among the 6 simulation centers used for neonatal and infant resuscitation training, course frequency varied: i) one training per month (n = 2), ii) one every 2 months (n = 1), iii) one every 3 months (n = 1), and iv) one per year (n = 1). These numbers corresponded to a median of 6 training sessions (1–12) per year and institution. One simulation center was commencing operations during the period of the survey and information on training frequency was not provided. At the 17 institutions which owned simulation equipment, the median training interval was 4 training units (1–12) per year per institution. Overall, 4/17 institutions carried out one training per month, 2/17 one every 2 months, 3/17 one every 3 months, 2/17 one every 4 months, 3/17 one every 6 months, and 1/17 one per year. One institution had recently implemented resuscitation training for pediatric trainees and, therefore, was not able to provide data on course intervals. Another institution did not provide an answer to this question.
6 simulation centers were used for neonatal and infant resuscitation training of pediatric trainees; however, 2 neonatal centers did not utilize available simulation centers for postgraduate training at all. The majority of neonatal institutions had at least low-fidelity simulation equipment at their disposal, which was used for emergency training of physicians and nursing staff. Simulation sessions were mainly performed in clinical locations (e. g. delivery rooms), which enhances the required suspension of disbelief and might further improve the educational experience [13]. 5 institutions named financial restrictions as the main reason why simulation equipment was not available. This is not surprising, given the significant costs especially of fully interactive patient simulators. High-fidelity simulation for resident training is utilized by only 29 % of emergency medicine programs in the United States and costs have been identified as the main barrier [19], which is consistent with our results. However, high-fidelity simulators are no prerequisite for effective and educationally valuable simulation training, as the mannequin itself constitutes only one element of SBME [29]. Low-fidelity simulation also results in consistent performance improvement, and the average advantage of high-fidelity simulation compared to low-fidelity training may range from 1–2 % [21]. For centers with limited resources, utilizing simulation equipment of lower technical fidelity or sharing simulation facilities and simulators with other healthcare institutions may constitute possibilities of cost-efficient training [9]. E-learning and screen-based simulation are further effective training options for low resource countries [3, 22]. In addition, simulation programs may have the potential to actually reduce healthcare expenditures; Cohen et al. [5] reported that by significantly lowering the incidence of catheter-related infections in an intensive care unit through simulation-based training, more than $700 000 were saved, corresponding to a 7:1 rate of return on the training investment.
Team training
Skill retention
5 simulation centers were utilized for interdisciplinary resuscitation training with other medical specialties (e. g. obstetrics or anesthesiology) and team training (physicians and nursing staff). Among the 17 institutions with simulation equipment at their disposal, 8/17 (47.1 %) carried out interdisciplinary training with
Frequency of simulation sessions varied widely among neonatal institutions. The wide range of training intervals reflects the long-known problem that cognitive and technical skills are not sustained over time. Bould et al. [4] demonstrated that 17 months after NRP certification, none of 32 participants was able
Skill retention
Mileder LP et al. Compliance with Guidelines Recommending … Klin Padiatr 2014; 226: 24–28
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as an instructional methodology as well as theoretical education such as seminars. At 20/25 institutions (80 %) Newborn Life Support (NLS) and/or European Paediatric Life Support (EPLS) courses were part of the training regimen. 14 of these 20 institutions (70 %) were covering NLS/EPLS course fees at least partially; 4 further institutions (20 %) recommended participation in either course but did not offer financial support for trainees. No institution had the infrastructure to provide virtual education (e. g. interactive computer programs or training videos).
Original Article 27
to perform all life-saving steps correctly during simulated resuscitations. This is further supported by trials demonstrating that resuscitation skills and knowledge deteriorate within months after initial training [6, 11, 15]. Although researchers and educators are aware of the problem of knowledge and skill deterioration, optimal booster strategies and intervals have not been identified [24].
Conclusion
▼
The majority of neonatal institutions in Austria utilized SBME, but educational practice varied widely among surveyed centers. As current resuscitation guidelines lack specific suggestions regarding the application of SBME, we suggest a national consensus agreement on best practices for simulation-based neonatal and infant resuscitation training.
Team training
A number of studies have reported that SBME correlates with significantly improved patient safety and health [2, 8, 23]. However, current resuscitation guidelines neither recommend any specific course format, training interval or assessment method nor take mannequin, environmental or psychological fidelity into account [16, 28]. Hence, we suggest a national consensus statement regarding the use of SBME for neonatal and infant resuscitation training, which should be based on existing medical education literature. The consensus paper should discuss minimal personnel and technical requirements and contain suggestions for contents, course formats, instructional methodologies, and assessment of trainees, corresponding to the guidelines on emergency simulation training by the German Society for Neonatology and Pediatric Intensive Care [10].
Study limitations We used a self-designed questionnaire, as there was no psychometrically tested questionnaire available for our study question. The corresponding author designed the initial version of the questionnaire and all 4 co-authors independently tested it for clarity and comprehensibility. The high number of institutions using SBME as an instructional methodology may in part be explained through the varying definitions and applications of the term ‘simulation’ [9]. Although we explained relevant terms in our questionnaire and used clear language, there may have been different interpretations of some questions on behalf of survey participants. We did not assess qualification, faculty requirements or numbers of simulation instructors employed at surveyed institutions, which is a limitation of the study. Although assessment of associated costs would have been another very interesting question, this topic would have been difficult to evaluate and, therefore, was not included in our questionnaire.
Acknowledgements
▼
G.M. Schmölzer is recipient of a Banting Postdoctoral Fellowship, Canadian Institute of Health Research, and an Alberta Innovate – Health Solution Clinical Fellowship.
Conflict of interest: L. P. Mileder works part-time as an instructor at the Clinical Skills Center, Medical University of Graz, and is involved in simulation training for medical students and (post-) graduate faculty. J. Schwindt is CEO of “SIMCharacters GmbH” which is offering simulation training in Europe. Affiliations Clinical Skills Center, Medical University of Graz, Austria 2 Department of Pediatrics, Division of Neonatology, Medical University of Graz, Austria 3 Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Austria 4 Department of Pediatrics, Academic Teaching Hospital Landeskrankenhaus Feldkirch, Austria 5 Department of Pediatrics, University of Alberta, Edmonton, Canada 6 Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada 1
References 1 Anderson JM, Warren JB. Using simulation to enhance the acquisition and retention of clinical skills in neonatology. Semin Perinatol 2011; 35: 59–67 2 Andreatta P, Saxton E, Thompson M et al. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med 2011; 12: 33–38 3 Biese KJ, Moro-Sutherland D, Furberg RD et al. Using screen-based simulation to improve performance during pediatric resuscitation. Acad Emerg Med 2009; 16: S71–S75 4 Bould MD, Hayter MA, Campbell DM et al. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009; 103: 570–575 5 Cohen ER, Feinglass J, Barsuk JH et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc 2010; 5: 98–102 6 Curran VR, Aziz K, O’Young S et al. Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills. Teach Learn Med 2004; 16: 157–164 7 Donoghue AJ, Durbin DR, Nadel FM et al. Effect of high-fidelity simulation on Pediatric Advanced Life Support training in pediatric house staff: a randomized trial. Pediatr Emerg Care 2009; 25: 139–144 8 Draycott TJ, Crofts JF, Ash JP et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112: 14–20 9 Fritz PZ, Gray T, Flanagan B. Review of mannequin-based high-fidelity simulation in emergency medicine. Emerg Med Australas 2008; 20: 1–9 10 German Society for Neonatology and Pediatric Intensive Care. Ausführungsempfehlungen für Simulationstraining in der PädInt. 2012. Available at: http://www.gnpi.de/cms2/images/attachments/stat ic/459_Ausfuehrungsempfehlungen_der %20_GNPI_fuer_Teamtrain ingskurse_fuer_innerklinische_und_klinische_Kindernotfaelle.pdf [Accessed June 15, 2013] 11 Grant EC, Marczinski CA, Menon K. Using pediatric advanced life support in pediatric residency training: does the curriculum need resuscitation? Pediatr Crit Care Med 2007; 8: 433–439
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A Joint Commission report suggested that 72 % of perinatal mortality and morbidity is caused by insufficient or ineffective communication [14]. Hence, the implementation of team training has been recommended to improve communication and teamwork. Morey et al. [20] showed that multidisciplinary crew/crisis resource management training for emergency department staff resulted in a significant decrease in clinical error rate from 30.9 % to 4.4 %. The majority of surveyed institutions in Austria have implemented team training including physicians and nursing staff. Unfortunately, there is a current lack of interdisciplinary resuscitation training involving physicians of other medical specialties, leaving an important aspect of SBME unused. Introduction of team training in low resource areas may result in a significant decrease in perinatal mortality and morbidity, which could be achieved by combining obstetric and neonatal simulation training and having disciplines learn from each other.
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12 Halamek LP. The simulated delivery-room environment as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation. Semin Fetal Neonatal Med 2008; 13: 448–453 13 Halamek LP, Kaegi DM, Gaba DM et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics 2000; 106: e45 14 Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert – Issue 30: Preventing infant death and injury during delivery. 2004. Available at: http://www.jointcommission.org/ assets/1/18/SEA_30.PDF [Accessed December 16, 2012] 15 Kaczorowski J, Levitt C, Hammond M et al. Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. Fam Med 1998; 30: 705–711 16 Mancini ME, Soar J, Bhanji F et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122: S539–S581 17 McGaghie WC, Issenberg SB, Petrusa ER et al. A critical review of simulation-based medical education research: 2003–2009. Med Educ 2010; 44: 50–63 18 McGaghie WC, Issenberg SB, Petrusa ER et al. Effect of practice on standardised learning outcomes in simulation-based medical education. Med Educ 2006; 40: 792–797 19 McLaughlin SA, Bond W, Promes S et al. The status of human simulation training in emergency medicine residency programs. Simul Healthc 2006; 1: 18–21 20 Morey JC, Simon R, Jay GD et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002; 37: 1553–1581
Compliance with Guidelines Recommending the Use of Simulation for Neonatal and Infant Resuscitation Training in Austria
Authors
L. P. Mileder1, 2, B. Urlesberger2, J. Schwindt3, B. Simma4, G. M. Schmölzer2, 5, 6
Affiliations
Affiliation addresses are listed at the end of the article
Key words ▶ newborn ● ▶ infant ● ▶ resuscitation ● ▶ education ● ▶ simulation ●
Abstract
Zusammenfassung
Background: Current international resuscitation guidelines recommend simulation for the training of neonatal and infant resuscitation. We aimed at assessing compliance rates with these recommendations in Austria. Method: We performed a national questionnaire survey among 31 neonatal institutions in Austria. Results: 25 questionnaires (80.6 %) were analyzed. 22/25 institutions (88 %) used simulation as an instructional modality. 8 institutions (32 %) had access to medical simulation centers, with 6/8 being used for neonatal and infant resuscitation training. Simulation equipment was available at 17/25 institutions (68 %), with a median of 1 part-task trainer (0–2), 2 low-fidelity resuscitation mannequins (0–10), and 0 high-fidelity patient simulators (0–7). Resuscitation training frequency varied widely, ranging from one training per month to one training per year. 5 simulation centers utilized interdisciplinary resuscitation training with other medical specialties and team training including physicians and nursing staff. Of the 17 institutions with simulation equipment at their disposal, 8 (47.1 %) carried out interdisciplinary training and 13 (76.5 %) performed teamoriented training sessions. Discussion/Conclusion: The majority of surveyed institutions adopted simulation for neonatal and infant resuscitation training according to current guidelines and had simulation equipment at their disposal. However, educational practice varied widely, especially in regard to training frequency. Therefore, we suggest a national consensus agreement on best practices in simulation-based neonatal and infant resuscitation training.
Hintergrund: Aktuelle internationale Reanimationsrichtlinien empfehlen die Nutzung von Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung. Wir untersuchten die Umsetzung dieser Empfehlungen in Österreich. Methoden: Wir führten eine nationale Umfrage mittels Fragebögen an 31 neonatologischen Abteilungen in Österreich durch. Ergebnisse: 25 Fragebögen (80,6 %) wurden ausgewertet. 22/25 Institutionen (88 %) nutzten Simulation als Ausbildungsmethode. 8 Institutionen (32 %) hatten Zugang zu einem medizinischen Simulationszentrum, wovon 6 für Neugeborenenund Säuglingsreanimationsausbildung verwendet wurden. Simulationsmaterial war an 17/25 Institutionen (68 %) verfügbar, mit einem Median von 1 Einzelfertigkeitentrainer (0–2), 2 Low-fidelity-Simulatoren (0–10) und 0 High-fidelity-Patientensimulatoren (0–7). Die Trainingsfrequenzen zeigten eine ausgeprägte Variabilität und reichten von einem Training im Monat zu einem Training im Jahr. 5 Simulationszentren hielten interdisziplinäre Reanimationstrainings mit anderen Fachrichtungen und Teamtrainings von Ärzten und Pflegepersonal ab. Von den 17 Institutionen mit eigenem Simulationsmaterial veranstalteten 8 (47,1 %) interdisziplinäre Trainings und 13 (76,5 %) teamorientierte Trainings. Diskussion/Schlussfolgerung: Die Mehrheit der befragten Institutionen nutzte Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung gemäß aktuellen Richtlinien und verfügte über eigenes Simulationsmaterial. Die Umsetzung war jedoch sehr heterogen, insbesondere in Bezug auf die Trainingshäufigkeit. Wir empfehlen daher die Erstellung eines nationalen Konsensuspapiers zur Durchführung simulationsbasierter Ausbildung in der Neugeborenenund Säuglingsreanimation.
Schlüsselwörter ▶ Neugeborenes ● ▶ Säugling ● ▶ Reanimation ● ▶ Ausbildung ● ▶ Simulation ●
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1361106 Published online: January 16, 2014 Klin Padiatr 2014; 226: 24–28 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Lukas Peter Mileder Department of Pediatrics Division of Neonatology Medical University of Graz Auenbruggerplatz 38/1 8036 Graz Austria Tel.: + 43/699/11751 318 Fax: + 43/316/38513 953 [email protected]
▼
Mileder LP et al. Compliance with Guidelines Recommending … Klin Padiatr 2014; 226: 24–28
▼
Downloaded by: National University of Singapore. Copyrighted material.
Die Umsetzung von Empfehlungen zur Nutzung von Simulation in der Neugeborenen- und Säuglingsreanimationsausbildung in Österreich
Original Article 25 Abbreviations
Table 1 Survey results.
▼
Number of institutions (n)
European Paediatric Life Support Newborn Life Support Neonatal Resuscitation Program Simulation-based medical education
Questionnaires analyzed
Background
▼
The Joint Commission on Accreditation of Healthcare Organizations, reporting on preventing infant death and injury during delivery, highlighted that failures in team communication account for more than two thirds of perinatal mortality and morbidity [14]. The report suggested using team training to improve communication and teamwork, and to conduct clinical drills to assess staff performance. Accordingly, current resuscitation guidelines recommend implementing simulation as an educational method for neonatal and infant resuscitation training [26, 28]. Simulation is “an education technique that allows interactive, and at time immersive, activity by recreating all or part of a clinical experience” [25]. Although verbal role playing and the use of part-task trainers for technical skills practice represent some form of simulation training, the terms ‘simulation-based training’ or ‘simulation-based medical education’ (SBME) usually describe the utilization of human actors and realistic, fully interactive patient simulators [12]. SBME offers numerous advantages, all of whom are critical when training healthcare professionals: i) controlled and risk-free learning, ii) repetitive deliberate practice, iii) customizability of training experiences to individual needs, and iv) objective assessment of and feedback on trainees’ performance [17, 25, 27]. Neonatal and infant resuscitation are high acuity, low occurrence events, which – although arising infrequently – still require high levels of cognitive and technical competency as well as mental preparedness [7]. Such events lend themselves well to simulationbased training [12], and SBME has been identified as “a highly effective instructional strategy for the acquisition and retention of skills requisite to competent performance in dynamic, high-pressure, high-consequence environments” such as delivery rooms [1].
Low- vs. high-fidelity simulation The term ‘fidelity’ refers to the degree to which a simulated experience replicates reality [9]. The simulator’s technical capability, environmental fidelity and the training’s psychological fidelity contribute to the overall fidelity of a simulation and should be adapted according to respective learning objectives [9]. Although both high- and low-fidelity simulation result in consistent performance improvement [21], a dose-response-like relationship between the numbers of practice hours and standardized learning outcomes has been described only for highfidelity simulator training [18]. The aim of this study was i) to assess the current availability and ii) the application of simulation-based neonatal and infant resuscitation training in pediatric hospitals in Austria.
Methods
▼
We performed a national questionnaire survey. The questionnaire (Appendix online) consisted of both open and closed
Resuscitation training methodologies: – supervised clinical practice – simulation-based training – theoretical education – NLS/EPLS courses Clinical skills/medical simulation center access: – availability at level II vs. level III centers – neonatal/infant resuscitation training – interdisciplinary training/team training Available simulation equipment: – training of medical staff – training of nursing staff – training at clinical locations – training in lecture halls and seminar rooms – team training – interdisciplinary training
n = 25/31 (80.6 %) 25/25 (100 %) 22/25 (88 %) 22/25 (88 %) 20/25 (80 %) 8/25 (32 %) 3/17 vs. 5/8* 6/8 (75 %) 5/8 (62.5 %) 17/25 (68 %) 17/17 (100 %) 15/17 (88.2 %) 12/17 (70.6 %) 10/17 (58.8 %) 13/17 (76.5 %) 8/17 (47.1 %)
NLS: Newborn Life Support; EPLS: European Paediatric Life Support; * p < 0.05
questions and focused on 3 major categories: i) demographic data of institutions (e. g. level of care, number of births per year), ii) training methodologies for residents and fellows, and availability of simulation equipment at university, hospital or department level (e. g. low-fidelity mannequins, high-fidelity patient simulators), and iii) utilization of simulation equipment (e. g. training frequency, interdisciplinary and team training). Space was provided for comments. In December 2012, the questionnaire was sent to consultant neonatologists at 31 level II and III neonatal centers in Austria, all with teaching responsibilities in neonatal care. In Austria, level III hospitals represent tertiary care centers (maximum medical care provided). The questionnaire was sent by e-mail with a covering letter describing the aim of the study, the intent to analyze and publish provided data, and names and e-mail addresses of involved researchers. Questionnaires could be answered electronically or printed, completed by hand, and returned by fax. If not returned after 8 weeks, a telephone call was made and the questionnaire administered a second time. The study period lasted from December 2012 to April 2013. Analyses consisted of frequency analysis (quantitative and qualitative data) and descriptive statistics. Percentages were calculated for categorical variables and means ( ± standard deviation) or median (range) for continuous data. We used Fisher’s exact test for categorical variables and Student’s t-test for independent samples to compare continuous variables. A p-value of less than 0.05 was deemed statistically significant. Statistical analysis was performed using IBM® SPSS Statistics, Version 20.
Results
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A total number of 26/31 questionnaires (83.9 %) were returned. However, one questionnaire was excluded due to missing pages, which left 25/31 questionnaires (80.6 %) for analysis. Selected ▶ Table 1. results are summarized in ● All 25 institutions reported neonatal and infant resuscitation training for pediatric and neonatal trainees through supervised clinical practice. In addition, 22/25 institutions (88 %) used SBME
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EPLS NLS NRP SBME
26 Original Article
Low- vs. high-fidelity simulation Overall, 8/25 institutions (32 %) had access to a clinical skills or medical simulation center, with significantly higher numbers of simulation centers available at level III (n = 5/8) compared to level II institutions (n = 3/17; p < 0.05). The most common purpose of these facilities was postgraduate neonatal and infant resuscitation training (n = 6/8). Simulation equipment was directly available at 17/25 institutions (68 %), which was evenly distributed between secondary and tertiary pediatric centers. Each institution had a median number of 1 part-task trainer (0–2), 2 low-fidelity resuscitation mannequins (0–10), and 0 high-fidelity patient simulators (0–7) available. The equipment was used for the training of medical staff in all 17 institutions, for nursing staff in 15/17 institutions (88.2 %), and for undergraduate medical students in 5/17 institutions (29.4 %). Resuscitation training was mainly carried out at clinical locations (e. g. hospital ward, intensive care unit, delivery room; n = 12/17) and/or in lecture halls and seminar rooms (n = 10/17). Institutions without simulation equipment at their disposal (8/25 institutions; 32 %) were asked to specify reasons. Availability of a simulation center and financial restrictions were named 5 times each. One institution made use of external simulation training, and another institution reported to lease simulation equipment biannually for training purposes. No institution acknowledged preferring non-simulation-based education.
physicians of other medical specialties and 13/17 (76.5 %) performed team training of pediatricians and nursing staff.
Discussion
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If utilized effectively, SBME is a powerful instructional methodology that has been recommended by neonatal and infant resuscitation guidelines [26, 28]. The aim of this study was to investigate the compliance with these recommendations in Austria. Almost all surveyed institutions (88 %) adopted simulation for resuscitation training as recommended by current guidelines. Hands-on training in the real healthcare environment, theoretical instruction, and NLS/EPLS courses were also utilized for resuscitation training. No institution was utilizing virtual training methodologies, although e-learning has the potential to improve both pediatric advanced life support knowledge and skills [22].
Low- vs. high-fidelity simulation
Among the 6 simulation centers used for neonatal and infant resuscitation training, course frequency varied: i) one training per month (n = 2), ii) one every 2 months (n = 1), iii) one every 3 months (n = 1), and iv) one per year (n = 1). These numbers corresponded to a median of 6 training sessions (1–12) per year and institution. One simulation center was commencing operations during the period of the survey and information on training frequency was not provided. At the 17 institutions which owned simulation equipment, the median training interval was 4 training units (1–12) per year per institution. Overall, 4/17 institutions carried out one training per month, 2/17 one every 2 months, 3/17 one every 3 months, 2/17 one every 4 months, 3/17 one every 6 months, and 1/17 one per year. One institution had recently implemented resuscitation training for pediatric trainees and, therefore, was not able to provide data on course intervals. Another institution did not provide an answer to this question.
6 simulation centers were used for neonatal and infant resuscitation training of pediatric trainees; however, 2 neonatal centers did not utilize available simulation centers for postgraduate training at all. The majority of neonatal institutions had at least low-fidelity simulation equipment at their disposal, which was used for emergency training of physicians and nursing staff. Simulation sessions were mainly performed in clinical locations (e. g. delivery rooms), which enhances the required suspension of disbelief and might further improve the educational experience [13]. 5 institutions named financial restrictions as the main reason why simulation equipment was not available. This is not surprising, given the significant costs especially of fully interactive patient simulators. High-fidelity simulation for resident training is utilized by only 29 % of emergency medicine programs in the United States and costs have been identified as the main barrier [19], which is consistent with our results. However, high-fidelity simulators are no prerequisite for effective and educationally valuable simulation training, as the mannequin itself constitutes only one element of SBME [29]. Low-fidelity simulation also results in consistent performance improvement, and the average advantage of high-fidelity simulation compared to low-fidelity training may range from 1–2 % [21]. For centers with limited resources, utilizing simulation equipment of lower technical fidelity or sharing simulation facilities and simulators with other healthcare institutions may constitute possibilities of cost-efficient training [9]. E-learning and screen-based simulation are further effective training options for low resource countries [3, 22]. In addition, simulation programs may have the potential to actually reduce healthcare expenditures; Cohen et al. [5] reported that by significantly lowering the incidence of catheter-related infections in an intensive care unit through simulation-based training, more than $700 000 were saved, corresponding to a 7:1 rate of return on the training investment.
Team training
Skill retention
5 simulation centers were utilized for interdisciplinary resuscitation training with other medical specialties (e. g. obstetrics or anesthesiology) and team training (physicians and nursing staff). Among the 17 institutions with simulation equipment at their disposal, 8/17 (47.1 %) carried out interdisciplinary training with
Frequency of simulation sessions varied widely among neonatal institutions. The wide range of training intervals reflects the long-known problem that cognitive and technical skills are not sustained over time. Bould et al. [4] demonstrated that 17 months after NRP certification, none of 32 participants was able
Skill retention
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as an instructional methodology as well as theoretical education such as seminars. At 20/25 institutions (80 %) Newborn Life Support (NLS) and/or European Paediatric Life Support (EPLS) courses were part of the training regimen. 14 of these 20 institutions (70 %) were covering NLS/EPLS course fees at least partially; 4 further institutions (20 %) recommended participation in either course but did not offer financial support for trainees. No institution had the infrastructure to provide virtual education (e. g. interactive computer programs or training videos).
Original Article 27
to perform all life-saving steps correctly during simulated resuscitations. This is further supported by trials demonstrating that resuscitation skills and knowledge deteriorate within months after initial training [6, 11, 15]. Although researchers and educators are aware of the problem of knowledge and skill deterioration, optimal booster strategies and intervals have not been identified [24].
Conclusion
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The majority of neonatal institutions in Austria utilized SBME, but educational practice varied widely among surveyed centers. As current resuscitation guidelines lack specific suggestions regarding the application of SBME, we suggest a national consensus agreement on best practices for simulation-based neonatal and infant resuscitation training.
Team training
A number of studies have reported that SBME correlates with significantly improved patient safety and health [2, 8, 23]. However, current resuscitation guidelines neither recommend any specific course format, training interval or assessment method nor take mannequin, environmental or psychological fidelity into account [16, 28]. Hence, we suggest a national consensus statement regarding the use of SBME for neonatal and infant resuscitation training, which should be based on existing medical education literature. The consensus paper should discuss minimal personnel and technical requirements and contain suggestions for contents, course formats, instructional methodologies, and assessment of trainees, corresponding to the guidelines on emergency simulation training by the German Society for Neonatology and Pediatric Intensive Care [10].
Study limitations We used a self-designed questionnaire, as there was no psychometrically tested questionnaire available for our study question. The corresponding author designed the initial version of the questionnaire and all 4 co-authors independently tested it for clarity and comprehensibility. The high number of institutions using SBME as an instructional methodology may in part be explained through the varying definitions and applications of the term ‘simulation’ [9]. Although we explained relevant terms in our questionnaire and used clear language, there may have been different interpretations of some questions on behalf of survey participants. We did not assess qualification, faculty requirements or numbers of simulation instructors employed at surveyed institutions, which is a limitation of the study. Although assessment of associated costs would have been another very interesting question, this topic would have been difficult to evaluate and, therefore, was not included in our questionnaire.
Acknowledgements
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G.M. Schmölzer is recipient of a Banting Postdoctoral Fellowship, Canadian Institute of Health Research, and an Alberta Innovate – Health Solution Clinical Fellowship.
Conflict of interest: L. P. Mileder works part-time as an instructor at the Clinical Skills Center, Medical University of Graz, and is involved in simulation training for medical students and (post-) graduate faculty. J. Schwindt is CEO of “SIMCharacters GmbH” which is offering simulation training in Europe. Affiliations Clinical Skills Center, Medical University of Graz, Austria 2 Department of Pediatrics, Division of Neonatology, Medical University of Graz, Austria 3 Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Austria 4 Department of Pediatrics, Academic Teaching Hospital Landeskrankenhaus Feldkirch, Austria 5 Department of Pediatrics, University of Alberta, Edmonton, Canada 6 Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada 1
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A Joint Commission report suggested that 72 % of perinatal mortality and morbidity is caused by insufficient or ineffective communication [14]. Hence, the implementation of team training has been recommended to improve communication and teamwork. Morey et al. [20] showed that multidisciplinary crew/crisis resource management training for emergency department staff resulted in a significant decrease in clinical error rate from 30.9 % to 4.4 %. The majority of surveyed institutions in Austria have implemented team training including physicians and nursing staff. Unfortunately, there is a current lack of interdisciplinary resuscitation training involving physicians of other medical specialties, leaving an important aspect of SBME unused. Introduction of team training in low resource areas may result in a significant decrease in perinatal mortality and morbidity, which could be achieved by combining obstetric and neonatal simulation training and having disciplines learn from each other.
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