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Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Simulation and education
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Increasing pediatric resident simulated resuscitation performance: A standardized simulation-based curriculum夽
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Kimberly Stone a,∗ , Jennifer Reid a , Derya Caglar a , Ana Christensen b , Bonnie Strelitz b , Li Zhou c , Linda Quan a a
Department of Pediatrics, University of Washington School of Medicine and Division of Emergency Medicine, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States b Center for Clinical and Translational Research, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States c Incyte Corporation, Experimental Stations E361/256A, Route 141 and Henry Clay Road, Wilmington, DE 19880, United States
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Article history: Received 20 December 2013 Received in revised form 24 April 2014 Accepted 1 May 2014
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Keywords: Graduate medical education Team assessment Pediatric resuscitation Simulation Residency curriculum
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1. Introduction
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Aim: Studies demonstrating the impact of resuscitation simulation curricula on performance are limited. Our objective was to create and evaluate a simulation-based resuscitation curriculum’s impact on pediatric residents’ performance in a simulated resuscitation. Methods: We developed a standardized simulation-based pediatric resident resuscitation curriculum consisting of nine modules, incorporating four domains (basic skills, airway/breathing, circulation and team management) and specific topics (e.g., anaphylaxis). Each module was presented four times over the academic year. Evaluation of the curriculum consisted of pre- and post-intervention video-recorded performances of a simulated pediatric resuscitation by 10 resident resuscitation teams, scored using the Simulation Team Assessment Tool (STAT). The effectiveness of the standardized curriculum on medical (basics, airway/breathing, circulation) and team management, and on knowledge test scores was evaluated by comparing pre- and post-intervention STAT scores using unpaired two-sided T-test. The impact of group curriculum participation on team performance (STAT scores) was analyzed using linear regression. Results: Overall team performance STAT scores increased post-intervention (mean pre-test 0.61, post-test 0.74, p < 0.001), as did management of the basics of resuscitation, airway/breathing and teamwork (mean basics: pre 0.46, post 0.62, p = 0.001; mean airway/breathing: pre 0.63, post 0.76, p = 0.01; mean teamwork: pre 0.61, post 0.79, p = 0.003). Regression analysis provided evidence for a training “dose–response” among the post-intervention teams, with teams exposed to more training achieving higher performance scores (p = 0.004). Conclusions: We created a standardized simulation-based pediatric resuscitation curriculum that increased pediatric residents’ scores on medical management and teamwork skills in a dose dependent relationship. © 2014 Published by Elsevier Ireland Ltd.
Pediatric residents lack real resuscitation experience,1–3 but are required to learn resuscitation skills during their training.4 Structured curricula can improve pediatric resident resuscitation
夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.05.005. ∗ Corresponding author at: Division of Emergency Medicine, Seattle Children’s Hospital, 4800 Sand Point Way NE, MB.7.520, Seattle, WA, 98105, United States. E-mail address: [email protected] (K. Stone).
knowledge, skills,5–7 comfort8 and leadership.5,6 Early studies evaluating structured curricula did not incorporate simulation.5,6 Simulation improves decision-making and procedural skills for low-frequency, high-acuity events.9–13 It would follow that simulation could be used to improve pediatric resuscitation skills and performance. One study of pediatric resuscitation training using simulation showed that the use of simulation for pediatric advanced life support (PALS) training improved cognitive performance for pediatric house staff.14 In addition to the increased use of simulation, there is growing interest in teamwork to improve patient safety. Teamwork skills encompass having a common purpose, delineating clear roles and responsibilities, engaging in effective communication
http://dx.doi.org/10.1016/j.resuscitation.2014.05.005 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
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and having team members who monitor themselves and others for performance gaps.15–17 Improved teamwork skills improves patient safety through reductions in adverse events and complications.18–20 Simulation is effective at teaching, evaluating, and improving teamwork skills.21–24 Studies also demonstrate that teamwork improvements translate to improvements in clinical performance in simulated environments.22–24 Only one study has incorporated both simulation and teamwork training into a pediatric mock code resuscitation curriculum.25 While this study demonstrated improvement in resident selfassessment surveys, it did not evaluate performance.
Our objective was to create a standardized high-technology simulation-based curriculum that incorporates teamwork skills and to evaluate this curriculum’s impact on pediatric residents’ medical management and teamwork during simulated pediatric resuscitations. 2. Methods
Medical management Resuscitation SAMPLE basics history
Airway and breathing
Assessing airway and breathing Recognizing progressive respiratory distress/ impending respiratory failure
We conducted a pre- and post-intervention study, following the creation of a standardized high-technology, simulation-based pediatric resuscitation curriculum at Seattle Children’s Hospital (SCH), a
Seizure
Anaphylaxis
Hypovolemic shock
Septic shock
SVT
Vfib
Abdominal trauma
Closed head injury
Primary survey
Estimating weight
Updating families Secondary Survey
Primary survey Secondary Survey
SAMPLE history
Updating families
Assessing airway and breathing Airway measures and adjuncts BMV
Rapid sequence intubation Intubation technique and confirmation Gastric decompression
Supplemental oxygen; different types
Supporting airway and. breathing with cardiac disturbances
Supporting airway and. breathing with cardiac disturbances
Primary survey Secondary Survey Estimating weight Supporting airway and. breathing
Primary survey Secondary survey Updating families Assess airway and breathing Recognize need for airway protection RSI of trauma
Assessing pulses and perfusion
Timely and abundant IV access
Assessing heart rate
Assessing pulses
Assessing heart rate
IVF resuscitation
Assessing pulses and perfusion
Identifying abnormal cardiac rhythms Performing good quality CPR
Circulation
Identify compensated vs uncompensated shock Types IV access
Core clinical topics
Recognize status asthmaticus
Recognize status epilepticus
Treat anaphylaxis
Treat status asthmaticus
Treat status epilepticus
2nd dose or drip of Epi
Placing IO line IVS resuscitation Recognizing hypovolemic shock Identify reasons for hypovolemic shock
Identifying abnormal cardiac rhythms
Recognize and treat septic shock Distinguish compensated from uncompensated septic shock
Directed, closed-loop communication
Clear, welldefined roles and responsibilities
Situation awareness
Situation awareness
Clear roles and responsibilities
Recognizing shock in a trauma patient IV access
Volume resuscitation
Performing cardio version
Defibrillation
Recognize SVT
Recognize Vfib
Recognize abdominal trauma
Recognize closed head injury
Treat SVT
PALS algorithm for pulseless arrest
Identify common mechanisms for abdominal trauma Differential diagnosis of abdominal trauma
GCS
Create differential diagnosis for epilepticus Teamwork
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Table 1 Pediatric simulation-based resuscitation curriculum goals and objectives map. Asthma
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Directed, closed-loop communication
Situation awareness
Directed, closed-loop communication
Assessing neurological status
Clear, welldefined roles & responsibilities
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tertiary care pediatric training hospital, from August 2009 through September 2010. We recruited 20 teams to perform a simulated pediatric resuscitation: 10 independent teams each for the preand post-intervention phases. Participants were recruited from the University of Washington pediatric residency program. Each team consisted of one 1st year, one 2nd year and one 3rd year resident and two SCH Emergency Department (ED) nurses. Each resident participated in only one resuscitation team in each phase. Nurses performed standardized roles: refraining from initiating care or making suggestions. This study was approved by the Institutional Review Board at Seattle Children’s Hospital.
2.1. Curriculum development Lead authors (KS and JR) created a standardized simulationbased resuscitation curriculum for pediatric residents consisting of nine modules, incorporating basic resuscitation skills (e.g. obtaining a patient weight), airway/breathing management, circulation management, teamwork (e.g. having clear roles) and clinical topics (e.g. anaphylaxis). Content was derived from PALS26 and the Accreditation Council for Graduate Medical Education (ACGME).4 Teamwork content was derived from teamwork literature.27–31 We use the term medical management to describe basic resuscitation skills, airway/breathing, circulation and clinical topics. The curriculum was created using Kern’s framework for medical education.32 Table 1 lists medical management and teamwork learning objectives for each module. Ten experts in the fields of pediatric emergency medicine, critical care and graduate medical education reviewed the curriculum for content, feasibility and to confirm that expectations were appropriate for a pediatric resident. Using a modified-Delphi, iterative process, the curriculum was refined until experts reached consensus.
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2.2.2. Intervention: the curriculum From October 2009 through July 2010, the new curriculum replaced existing pediatric resident resuscitation education sessions. Previously, these occurred twice a month for the residents on the general pediatric wards, once a month for the residents in the ED and utilized both low and high-technology mannequins, with no formal curriculum and little emphasis on teamwork. During the intervention period, four simulation sessions occurred per month: two each in the pediatric wards and ED. Resident attendance was optional. Each of the nine teaching modules was conducted four times, for a total of 36 simulation sessions. Each simulation session was 30 min long, consisting of an introduction (review of the simulator and learning contract), resuscitation scenario and debriefing. Debriefings focused on medical management and teamwork learning objectives. One of the two authors (KS or JR) facilitated and debriefed all sessions. Sessions were video-recorded and reviewed for consistency and to assure learning objectives were met periodically throughout the intervention. After each module, all pediatric residents received an aggregate summary of the teams’ performance, highlighting what went well, opportunities for improvement, and a summary of the module’s learning objectives. 2.2.3. Post-intervention test Between August and September 2010, thirty pediatric residents were recruited to form 10 pediatric resident resuscitation teams, as in the pre-intervention test. Post-intervention participation did not require pre-intervention participation. Teams were constructed based strictly on scheduling availability. The post-intervention scenario included a modified patient history and vital signs but contained the same triggers to proceed as the pre-intervention scenario. Residents participated in only one resuscitation team, completed the same experience survey used in the pre-intervention test, a knowledge test and an additional survey about their experience with the standardized curriculum.
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2.2. Study sequence 2.3. Outcome measures
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2.2.1. Pre-intervention test Thirty pediatric residents were recruited to form 10 resuscitation teams. Residents provided written informed consent, completed a survey about previous experience and a 20 question knowledge test. Knowledge test questions came from retired PALS tests. All simulations used a standard set-up, including Laerdal SimBabyTM (Laerdal Corporation, Stockholm, Sweden) and the resuscitation room of the SCH ED. The team was oriented to the environment and provided a scripted clinical vignette. Each team performed one standardized resuscitation. The scenario (a two-year child in shock with subsequent apnea and ventricular fibrillation) was previously piloted. Teams could use cognitive aids, such as PALS algorithm cards. All simulations were facilitated and debriefed by one of the two authors (KS or JR), with standardized responses (e.g. capillary refill time, lab results). Facilitators did not intervene or redirect the team. The scenario was preprogrammed, proceeding based on predetermined times or interventions. Simulations were video-recorded from two angles. One camera provided a wide-angle view of the entire room; the second camera provided an up-close view of the human simulator from directly above. Following each simulation, the resuscitation team was debriefed and completed a questionnaire soliciting feedback about the simulation. Simulations were conducted over 6 weeks. Participants were asked to maintain confidentiality and blinded to the study goals.
The primary outcome measure was difference in overall team performance score on the Simulation Team Assessment Tool (STAT)33 between pre- and post-intervention resuscitation teams. Developed and validated for assessing team performance during a simulated pediatric resuscitation and with good inter-rater reliability, the STAT provides an overall team performance score as well as domain scores for the basics of resuscitation, airway/breathing, circulation and teamwork.33 Secondary outcome measures were differences between the pre- and post-intervention teams on the STAT domains of basics, airway/breathing, circulation and teamwork; differences in knowledge scores; and the impact of team exposure to the new curriculum on overall team STAT performance. 2.4. Raters and scoring All raters were experts in resuscitation, pediatric emergency medicine faculty members at the University of Washington and had participated in a one-time training session as previously described.33 Two raters independently scored each team’s video recorded performance using the STAT.33 Raters viewed pre- and post-intervention videos in arbitrary order without obvious visual clues to identify the timing of the video, in an attempt to remain blinded. Raters were allowed to watch the video recording as many times as necessary to obtain accurate scoring. Discussion was not
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allowed. The average of both raters’ scores was each team’s final score.
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STAT overall performance and domain scores were calculated for each team. The unpaired two-sided T-test was used to analyze differences between the pre- and post-intervention teams’ performance. The impact of group curriculum participation on the STAT overall performance score was analyzed using linear regression including only the post-intervention groups. Since individual experience was categorized as 0 sessions, 1–2 sessions or 3–4 sessions (Table 3), the exact overall number of sessions attended by each team was not retrievable. Instead, 1–2 sessions were counted as 1 “participation point” and 3–4 sessions as 2 points, and the team totals used as the predictor variable. An alternate predictor was the number of members who attended at least one session. Each resident received a knowledge score for both the pre- and post-intervention tests. Unpaired two-sided T-tests were used to analyze the differences between the pre- and post-intervention knowledge.
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Sixty residents participated in the pre- and post-intervention simulated resuscitations. Eight residents participated in both. Preand post-intervention residents did not differ with regard to prior experience with PALS, ACLS, simulation, or participation in mock or real codes. More post-intervention residents took PALS within the previous year (Table 2). Twenty-one of the 30 post-intervention residents (66%) attended at least one of the curriculum’s modules (Table 3). Of the nine that had not, eight were new interns who had limited opportunity to participate in the curriculum. The majority of residents attended modules focused on airway and breathing; few attended circulatory modules. Post-intervention residents who participated in the curriculum rated the modules on a Likert scale (1–5) as realistic, mean score 3.81 (0.81 SD), effective at teaching basic resuscitation skills, mean score 3.9 (0.83 SD), and effective at teaching teamwork skills, mean score 4.48 (0.68 SD). Residents rated the curriculum as important for preparing them to provide pediatric advanced life support, mean score 4.19 (0.98 SD). Resident teams’ post-intervention overall STAT scores were significantly higher than pre-intervention (mean pre-intervention 0.61 (95% CI 0.55, 0.67) vs post-intervention 0.74 (95% CI 0.71, 0.78), p < 0.001) (Table 4 and Fig. 1). STAT domain scores of basics, airway/breathing and teamwork were significantly higher (basic: mean pre-intervention 0.46 (95% CI 0.39, 0.53) vs post-intervention 0.62 (95% CI 0.55, 0.69), p = 0.0016; airway/breathing: mean preintervention 0.63 (95% CI 0.57, 0.69) vs post-intervention 0.76 (95% CI 0.67, 0.85), p = 0.0137; teamwork: mean pre-intervention 0.61 (95% CI 0.51, 0.70) vs post-intervention 0.8 (95% CI 0.72, 0.85), p = 0.0026). In the circulation domain, STAT scores were higher post-intervention than pre-intervention but did not reach statistical significance (mean pre-intervention 0.67 (95% CI 0.57, 0.77) vs post-intervention 0.76 (95% CI 0.72, 0.81), p = 0.075). Residents knowledge test scores did not differ pre- and post-intervention (mean 66.5 vs 68.7, respectively p = 0.308). All post-intervention teams had at least one team member who had participated in the standardized curriculum. One of the teams collectively attended 1–2 modules; five teams 3–4 modules and five teams ≥5 modules. Linear regression analyses conducted on the 10 post-intervention teams, using the overall STAT scores as the outcome and group participation as the explanatory variable,
Table 2 Resident participant characteristics and experience. Pre-intervention N = 30 n (%) Code experience Had ever taken a PALS class Most recent PALS class was within the last year Had ever taken an ACLS class Participated in high-fidelity simulation training in the past Number of previous sessions attended 1–2 3–4 ≥5 Had been active team member in a mock code in the previous 3 years Number of mock codes as a team member 1–2 3–4 ≥5 Number of mock codes as team leader 0 1 2 ≥3 Had been active team member in a real code in the previous 3 years Number of real codes as team member 1–2 3–4 ≥5 Number of real codes as team leader 0 1 2 ≥3
Q5 Post-intervention N = 30 n (%)
29 (97%) 25 (83%)
30 (100%) 30 (100%)*
21 (70%) 30 (100%)
20 (67%) 28 (93%)
10 (33%) 7 (23%) 13 (43%) 28 (93%)
5 (17%) 6 (20%) 17 (57%) 28 (93%)
13 (43%) 6 (20%) 9 (30%)
10 (33%) 6 (20%) 12 (40%)
8 (27%) 9 (30%) 7 (23%) 5 (17%) 20 (67%)
9 (30%) 7 (23%) 5 (17%) 7 (23%) 18 (60%)
12 (40%) 5 (17%) 3 (10%)
6 (20%) 9 (30%) 3 (10%)
14 (47%) 4 (13%) 1 (3%) 0 (0%)
15 (50%) 3 (10%) 0 (0%) 1 (3%)
showed that increased participation was significantly associated with the overall STAT score and teamwork sub-domain and positively associated with remaining sub-domain STAT scores (overall STAT score: score improvement (SE) per curriculum participation point 0.046 (0.012), p = 0.004; basic: 0.034 (0.036), p = 0.37; airway/breathing: 0.057 (0.042), p = 0.22; circulation: 0.024 (0.020), p = 0.28; teamwork: 0.069 (0.024), p = 0.02). 4. Discussion In this study a modular, standardized, simulation-based pediatric resident resuscitation curriculum that included teamwork training was associated with increased residents’ performance scores on a simulated resuscitation in overall performance, basics of resuscitation, airway and teamwork skills. The lack of a significant increase in resident team performance scores for the circulation domain could be due to the small sample size and the smaller number of participants who had attended circulation based modules. Participants reported that the curriculum was realistic and improved their self-efficacy. The curriculum format is consistent with the best practice model for resuscitation education: reduced course duration and distributed practice over time.34 Most follow-up studies of resuscitation performance following a single educational intervention show significant decay in knowledge and skills by 6 months after
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Fig. 1. Pre- and post-intervention test STAT overall scores.
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the course.5,35 However, in our study, residents demonstrated skills developed throughout the year in their post-intervention performance. This supports the model of distributed practice, in addition to traditional resuscitation courses, such as PALS, to mitigate skills decay.
Table 3 Post-intervention resident experience with the standardized resuscitation curriculum, N = 30. n (%) Participated in curriculum by attending at least one teaching session Did not participate in any teaching sessions because were new interns Number of teaching sessions attended 1–2 3–4 ≥5 Teaching modules attended Anaphylaxis Asthma Hypovolemic shock Septic shock Abdominal trauma SVT Head injury Ventricular fibrillation Seizures Airway/breathing modules Circulation modules
21 (70%) 8 (27%)
9 (30%) 12 (40%) 0 (0%) 5 (17%) 5 (17%) 12 (40%) 10 (33%) 4 (13%) 8 (27%) 4 (13%) 2 (7%) 8 (27%) 19 (63%) 12 (40%)
Experience with the curriculum, N = 21 (Likert scale 1–5) Standardized curriculum was realistic Standardized curriculum was effective at teaching basic resuscitation skills Standardized curriculum was effective at teaching code team leadership and behavioral skills Importance of standardized curriculum in teaching you pediatric advanced life support skills
Score (SD) 3.81 (0.81) 3.90 (0.83) 4.48 (0.68) 4.19 (0.98)
Knowledge scores were not impacted by the curriculum. The knowledge of the pediatric residents was high both pre- and postintervention. However, the post-intervention residents were able to translate their knowledge into improved performance on the simulated patient. The use of simulation-based medical education is particularly suited to allow for this translation because simulation-based learning offers deliberate practice.36 Ericsson37 identified the need for deliberate practice to reach expertise and for deliberate practice to include provision of immediate feedback, time for problem-solving and evaluation and opportunities for repeated performance. The curriculum in this study provided opportunities for deliberate practice and capitalized on the features of high-technology simulation to facilitate learning, such as feedback about performance, repetitive practice, progressive difficulty and clinical variation.34 This potentially contributed to the post-intervention residents’ ability to translate their knowledge to performance. The greatest increase in performance scores was in the STAT teamwork domain. It is possible that by improving teamwork skills, teams were more organized, better able to communicate and apply their knowledge, resulting in improved overall performance. Improved teamwork leading to improved clinical performance has been demonstrated in other studies.22–24 In their study on impact of team training of clinical efficacy of trauma resuscitation, Steinemann and colleagues24 demonstrated improved clinical performance in simulated scenarios following team training and, more importantly, continued improved teamwork and clinical performance in real trauma resuscitations 6 months after the training event. Thus, one major impact of our curriculum may be the integration of teamwork training. The fact that performance improved, even if only one team member experienced the curriculum, suggests an inoculation effect: only a small number of team members needed exposure to improve the care of the simulated patient. In addition, we observed a dose–response relationship – those participants with repeated exposure to the curriculum had increased performance scores in the post-intervention group. McGaghie and colleages38 reported
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Q6 Pre and post-intervention STAT overall and domain scores.
STAT score Basic score Airway score Circulation score Teamwork score a
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Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI]
Pre intervention N = 10
Post intervention N = 10
Pre to post changes mean (95% CI)
p-Valuea
0.609 (0.088)[0.55, 0.67] 0.456 (0.098)[0.39, 0.53] 0.627 (0.081)[0.57, 0.69] 0.669 (0.143)[0.57, 0.77] 0.606 (0.134)[0.51, 0.70]
0.744 (0.054)[0.71, 0.78] 0.621 (0.101)[0.55, 0.69] 0.756 (0.125)[0.67, 0.85] 0.765 (0.061)[0.72, 0.81] 0.785 (0.091)[0.72, 0.85]
0.135 (0.067, 0.204) 0.164 (0.071, 0.258) 0.128 (0.03, 0.227) 0.096 (−0.011, 0.203) 0.179 (0.071, 0.287)
0.0006** 0.0016** 0.0137* 0.0750 0.0026**
p-Value is for the comparison of STAT scores between post-intervention and pre-intervention.
a similar dose-response relationship following simulation-based learning with increasing hours of simulation-based practice leading to improved outcomes. Together the findings of a possible inoculation effect and a dose–response relationship suggest additional benefits of the curriculum leading to improved performance in the simulation resuscitation and potentially future areas of study.
5. Limitations Inherent in the pre- and post-intervention study design is whether observed results are due to the intervention. We are unaware of any additional systematic or educational changes during the intervention period regarding pediatric resuscitations that would have affected our results. It is also possible that the natural progression of skills impacted the results. We attempted to control for this by conducting the testing sessions at the same point in the academic year. The similar number of pre- and post-intervention residents who participated in mock or real resuscitations suggests that increased exposure to resuscitations alone would not explain these findings. Our intervention reached only a subset of all pediatric residents, as shown in Table 3. Participation may have been limited by competing clinical or educational demands. This is realistic for and comparable to other educational interventions. However, we would expect limited exposure to result in lower performance scores instead of the observed increased performance scores. It is possible that the eight residents who participated in both the pre- and post-intervention tests could skew the results if they recognized the scenario. However, in a multi-center study where participants were exposed to a similar simulation scenario at intervention, 3 and 6 months follow-up, there was no demonstrated improvement,39 arguing against participants ability to recognize similar scenarios. Selection bias may be present among the post-intervention test residents. Those who participated in the curriculum, felt it was useful, or became more confident or skilled, may have been more likely to participate in the post-intervention test. In addition, residents teams were created solely based on resident availability, due to scheduling challenges. The distribution of more experienced residents may not have been equivalent. Either of these could have potentially influenced their scores. This study was conducted in one institution, testing one resuscitation scenario, with a small number of faculty facilitators. Further study is needed to identify the reproducibility of the curriculum and elucidate the highest impact components of the curriculum on team performance. Next steps include incorporating this curriculum into other residency programs and refining the content for maximal performance improvement. Finally, the STAT was validated for use in simulated pediatric resuscitation; however, there has been no correlation of STAT performance with clinical performance or patient outcomes. Therefore, the meaning of an individual STAT score requires consideration. Ultimately, the challenge remains to demonstrate that improved performance in simulation translates to improvement in clinical pediatric resuscitations.
6. Conclusion We created a modular, standardized, simulation-based pediatric resuscitation curriculum with distributed practice over time that was well received by residents and associated with increased scores in pediatric residents’ medical management and teamwork skills in a simulation setting, in a dose-related response. Funding This study was supported by the Academic Enrichment Fund from the Department of Pediatrics, University of Washington Q4 School of Medicine. The funding source had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. Conflict of interest statement None of the authors have any conflicts of interest to declare. Acknowledgements We wish to thank The Learning and Simulation Center at Seattle Children’s Hospital who helped with all technical aspects of this project. We also thank Assaf Oron, PhD from Seattle Children’s Research Institute who provided valuable statistical input. References 1. White JRM, Shugerman R, Brownlee C, Quan L. Performance of advanced resuscitation skills by pediatric housestaff. Arch Pediatr Adolesc Med 1998;152:1232–5. 2. Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DRM. Assessing pediatric senior residents’ training in resuscitation: fund of knowledge, technical skills, and perception of confidence. Pediatr Emerg Care 2000;16:73–6. 3. Hunt EA, Patel S, Vera K, Shaffner DH, Pronovost PJ. Survey of pediatric resident experiences with resuscitation training and attendance at actual cardiopulmonary arrests. Pediatr Crit Care Med 2009;10:96–105. 4. Accreditation Council for Graduate Medical Education, Outcome project: Common Program Requirements – General Competencies, 2007. 5. Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Teaching resuscitation to pediatric residents: the effects of an intervention. Arch Pediatr Adolesc Med 2000;154:1049–54. 6. Quan L, Shugerman RP, Kunkel NC, Brownlee CJ. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course. Pediatrics 2001;108:e110. 7. Tofil NM, White ML, Manzella B, McGill D, Zinkan L. Initiation of a pediatric mock code program at a children’s hospital. Med Teach 2009;31:e241–7. 8. Friedman D, Zaveri P, O’Connell K. Pediatric mock code curriculum: improving resident resuscitations. Pediatr Emerg Care 2010;26:490–4. 9. Barsuk D, Ziv A, Lin G, et al. Using advanced simulation for recognition and correction of graps in airway and breathing management skills in prehospital trauma care. Anesth Analg 2005;100:803–9. 10. Marshall RL, Smith JS, Gorman PJ, Krummel TM, Haluck RS, Cooney RN. Use of a human patient simulator in the development of resident management skills. J Trauma 2001;51:17–21. 11. Hammond J. Simulation in critical care and trauma education and training. Curr Opin Crit Care 2004;10:325–9. 12. Mayo PH, Hackney JE, Mueck JT, Ribaudo V, Schneider RF. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med 2004;32:2422–7.
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13. McMahon GT, Monaghan C, Falchuk K, Gordon JA, Alexander EK. A simulatorbased curriculum to promote comparative and reflective analysis in an internal medicine clerkship. Acad Med 2005;80:84–9. 14. Donoghue AJ, Durbin DR, Nadel FM, Stryjewski GR, Kost SI, Nadkarni VM. Effect of high-fidelity simulation on pediatric advanced life support training in pediatric house staff: A randomized trial. Pediatr Emerg Care 2009;25:139–44. 15. Nestel D, Walker KRM, Simon RE, Aggarwal R, Andreatta P. Nontechnical skills: an inaccurate and unhelpful descriptor. Simul Healthc 2011;6:2–3. 16. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS. TeamSTEPPS web site. http://teamstepps.ahrq.gov/, 2011 [accessed 02.04.11]. 17. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18: 71–5. 18. Mann S, Marcus R, Sachs B. Lessons from the cockpit: how team training can reduce errors on L&D (Grand Rounds). Contemp OB/GYN 2006;51:34–7. 19. 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;37:1553–81. 20. Sexton JB. Symposium Presentation: Team Climate and Postoperative Sepsis in the Surgical Operating Room; 2006. 21. Sudikoff SN, Overly FL, Shapiro MJ. High-fidelity medical simulation as a technique to improve pediatric residents’ emergency airway management and teamwork. Pediatr Emerg Care 2009;25:651–6. 22. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Network 2013;32:26–33. 23. Frengley RW, Weller JM, Torrie J, et al. The effect of simulation-based training intervention on the performance of established critical care teams. Crit Care Med 2011;39:2605–11. 24. Steinemann S, Berg B, Skinner A, et al. In situ, multidisciplinary, simulationbased teamwork training improves early trauma care. J Surg Ed 2011;68: 472–7. 25. Sam J, Pierse M, Al-Qahtani A, Cheng A. Implementation and evaluation of a simulation curriculum for paediatric residency programs including just-in-time in situ mock codes. Paediatr Child Health 2012;17:e16–20. 26. Ralston M, Hazinski MF, Zaritsky AL, Schexnayder SM, Kleinman ME, editors. Pediatric advanced life support (PALS) manual. Dallas, TX: American Heart Association; 2006.
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27. Yule S, Flin R, Maran N, Rowley D, Youngson G, Paterson-Brown S. Surgeons’ nontechnical skills in the operating room: reliability testing of the NOTSS behavior rating system. World J Surg 2008;32:548–56. 28. Malec JF, Torsher LC, Dunn WF, et al. The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills. Simul Healthc 2007;2:4–10. 29. Kim J, Neilipovitz D, Cardinal P, Chiu M. A comparison of global rating scale and checklist scores in the validation of an evaluation tool to assess performance in the resuscitation of critically ill patients during simulated emergencies (abbreviated as “CRM Simulator Study IB”). Simul Healthc 2009;4:6–16. 30. Calhoun AW, Rider EA, Meyer EC, Lamiani GE, Truog RD. Assessment of communication skills and self-appraisal in the simulated environment: feasibility of multirater feedback with gap analysis. Simul Healthc 2009;4:22–9. 31. Hogan M, Pace D, Hapgood J, Boone D. Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. J Trauma 2006;61:1047–52. 32. Kern DE, Thomas PA, Hughes MT. Curriculum development for medical education: a six-step approach. 2nd ed. Baltimore: Johns Hopkins University Press; 2009. 33. Reid J, Stone K, Brown J, et al. The simulation team assessment tool (STAT): development, reliability and validation. Resuscitation 2012;83:879–86. 34. Hunt EA, Fiedor-Hamilton M, Eppich WJ. Resuscitation education: narrowing the gap between evidence-based resuscitation guidelines and performance using best educational practices. Pediatr Clin N Am 2008;55:1025–50. 35. 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;8:433–9. 36. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulationbased medical education with deliberate practice yield better results than traditional clinical education? a meta-analytic comparative review of the evidence. Acad Med 2011;86:706–11. 37. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med 2008;15:988–94. 38. McGaghie WC, Issenberg SB, Pertrusa ER, Scalese RJ. Effect of practice on standardized learning outcomes in simulation-based medical education. Med Educ 2006;40:792–7. 39. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric resuscitation using simulation and scripted debriefing (EXPRESS): a Multicenter, randomizedcontrolled trial. JAMA Pediatr 2013;167:528–36.
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Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Simulation and education
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Increasing pediatric resident simulated resuscitation performance: A standardized simulation-based curriculum夽
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Kimberly Stone a,∗ , Jennifer Reid a , Derya Caglar a , Ana Christensen b , Bonnie Strelitz b , Li Zhou c , Linda Quan a a
Department of Pediatrics, University of Washington School of Medicine and Division of Emergency Medicine, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States b Center for Clinical and Translational Research, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States c Incyte Corporation, Experimental Stations E361/256A, Route 141 and Henry Clay Road, Wilmington, DE 19880, United States
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Article history: Received 20 December 2013 Received in revised form 24 April 2014 Accepted 1 May 2014
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Keywords: Graduate medical education Team assessment Pediatric resuscitation Simulation Residency curriculum
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1. Introduction
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Aim: Studies demonstrating the impact of resuscitation simulation curricula on performance are limited. Our objective was to create and evaluate a simulation-based resuscitation curriculum’s impact on pediatric residents’ performance in a simulated resuscitation. Methods: We developed a standardized simulation-based pediatric resident resuscitation curriculum consisting of nine modules, incorporating four domains (basic skills, airway/breathing, circulation and team management) and specific topics (e.g., anaphylaxis). Each module was presented four times over the academic year. Evaluation of the curriculum consisted of pre- and post-intervention video-recorded performances of a simulated pediatric resuscitation by 10 resident resuscitation teams, scored using the Simulation Team Assessment Tool (STAT). The effectiveness of the standardized curriculum on medical (basics, airway/breathing, circulation) and team management, and on knowledge test scores was evaluated by comparing pre- and post-intervention STAT scores using unpaired two-sided T-test. The impact of group curriculum participation on team performance (STAT scores) was analyzed using linear regression. Results: Overall team performance STAT scores increased post-intervention (mean pre-test 0.61, post-test 0.74, p < 0.001), as did management of the basics of resuscitation, airway/breathing and teamwork (mean basics: pre 0.46, post 0.62, p = 0.001; mean airway/breathing: pre 0.63, post 0.76, p = 0.01; mean teamwork: pre 0.61, post 0.79, p = 0.003). Regression analysis provided evidence for a training “dose–response” among the post-intervention teams, with teams exposed to more training achieving higher performance scores (p = 0.004). Conclusions: We created a standardized simulation-based pediatric resuscitation curriculum that increased pediatric residents’ scores on medical management and teamwork skills in a dose dependent relationship. © 2014 Published by Elsevier Ireland Ltd.
Pediatric residents lack real resuscitation experience,1–3 but are required to learn resuscitation skills during their training.4 Structured curricula can improve pediatric resident resuscitation
夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.05.005. ∗ Corresponding author at: Division of Emergency Medicine, Seattle Children’s Hospital, 4800 Sand Point Way NE, MB.7.520, Seattle, WA, 98105, United States. E-mail address: [email protected] (K. Stone).
knowledge, skills,5–7 comfort8 and leadership.5,6 Early studies evaluating structured curricula did not incorporate simulation.5,6 Simulation improves decision-making and procedural skills for low-frequency, high-acuity events.9–13 It would follow that simulation could be used to improve pediatric resuscitation skills and performance. One study of pediatric resuscitation training using simulation showed that the use of simulation for pediatric advanced life support (PALS) training improved cognitive performance for pediatric house staff.14 In addition to the increased use of simulation, there is growing interest in teamwork to improve patient safety. Teamwork skills encompass having a common purpose, delineating clear roles and responsibilities, engaging in effective communication
http://dx.doi.org/10.1016/j.resuscitation.2014.05.005 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
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and having team members who monitor themselves and others for performance gaps.15–17 Improved teamwork skills improves patient safety through reductions in adverse events and complications.18–20 Simulation is effective at teaching, evaluating, and improving teamwork skills.21–24 Studies also demonstrate that teamwork improvements translate to improvements in clinical performance in simulated environments.22–24 Only one study has incorporated both simulation and teamwork training into a pediatric mock code resuscitation curriculum.25 While this study demonstrated improvement in resident selfassessment surveys, it did not evaluate performance.
Our objective was to create a standardized high-technology simulation-based curriculum that incorporates teamwork skills and to evaluate this curriculum’s impact on pediatric residents’ medical management and teamwork during simulated pediatric resuscitations. 2. Methods
Medical management Resuscitation SAMPLE basics history
Airway and breathing
Assessing airway and breathing Recognizing progressive respiratory distress/ impending respiratory failure
We conducted a pre- and post-intervention study, following the creation of a standardized high-technology, simulation-based pediatric resuscitation curriculum at Seattle Children’s Hospital (SCH), a
Seizure
Anaphylaxis
Hypovolemic shock
Septic shock
SVT
Vfib
Abdominal trauma
Closed head injury
Primary survey
Estimating weight
Updating families Secondary Survey
Primary survey Secondary Survey
SAMPLE history
Updating families
Assessing airway and breathing Airway measures and adjuncts BMV
Rapid sequence intubation Intubation technique and confirmation Gastric decompression
Supplemental oxygen; different types
Supporting airway and. breathing with cardiac disturbances
Supporting airway and. breathing with cardiac disturbances
Primary survey Secondary Survey Estimating weight Supporting airway and. breathing
Primary survey Secondary survey Updating families Assess airway and breathing Recognize need for airway protection RSI of trauma
Assessing pulses and perfusion
Timely and abundant IV access
Assessing heart rate
Assessing pulses
Assessing heart rate
IVF resuscitation
Assessing pulses and perfusion
Identifying abnormal cardiac rhythms Performing good quality CPR
Circulation
Identify compensated vs uncompensated shock Types IV access
Core clinical topics
Recognize status asthmaticus
Recognize status epilepticus
Treat anaphylaxis
Treat status asthmaticus
Treat status epilepticus
2nd dose or drip of Epi
Placing IO line IVS resuscitation Recognizing hypovolemic shock Identify reasons for hypovolemic shock
Identifying abnormal cardiac rhythms
Recognize and treat septic shock Distinguish compensated from uncompensated septic shock
Directed, closed-loop communication
Clear, welldefined roles and responsibilities
Situation awareness
Situation awareness
Clear roles and responsibilities
Recognizing shock in a trauma patient IV access
Volume resuscitation
Performing cardio version
Defibrillation
Recognize SVT
Recognize Vfib
Recognize abdominal trauma
Recognize closed head injury
Treat SVT
PALS algorithm for pulseless arrest
Identify common mechanisms for abdominal trauma Differential diagnosis of abdominal trauma
GCS
Create differential diagnosis for epilepticus Teamwork
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Table 1 Pediatric simulation-based resuscitation curriculum goals and objectives map. Asthma
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Directed, closed-loop communication
Situation awareness
Directed, closed-loop communication
Assessing neurological status
Clear, welldefined roles & responsibilities
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tertiary care pediatric training hospital, from August 2009 through September 2010. We recruited 20 teams to perform a simulated pediatric resuscitation: 10 independent teams each for the preand post-intervention phases. Participants were recruited from the University of Washington pediatric residency program. Each team consisted of one 1st year, one 2nd year and one 3rd year resident and two SCH Emergency Department (ED) nurses. Each resident participated in only one resuscitation team in each phase. Nurses performed standardized roles: refraining from initiating care or making suggestions. This study was approved by the Institutional Review Board at Seattle Children’s Hospital.
2.1. Curriculum development Lead authors (KS and JR) created a standardized simulationbased resuscitation curriculum for pediatric residents consisting of nine modules, incorporating basic resuscitation skills (e.g. obtaining a patient weight), airway/breathing management, circulation management, teamwork (e.g. having clear roles) and clinical topics (e.g. anaphylaxis). Content was derived from PALS26 and the Accreditation Council for Graduate Medical Education (ACGME).4 Teamwork content was derived from teamwork literature.27–31 We use the term medical management to describe basic resuscitation skills, airway/breathing, circulation and clinical topics. The curriculum was created using Kern’s framework for medical education.32 Table 1 lists medical management and teamwork learning objectives for each module. Ten experts in the fields of pediatric emergency medicine, critical care and graduate medical education reviewed the curriculum for content, feasibility and to confirm that expectations were appropriate for a pediatric resident. Using a modified-Delphi, iterative process, the curriculum was refined until experts reached consensus.
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2.2.2. Intervention: the curriculum From October 2009 through July 2010, the new curriculum replaced existing pediatric resident resuscitation education sessions. Previously, these occurred twice a month for the residents on the general pediatric wards, once a month for the residents in the ED and utilized both low and high-technology mannequins, with no formal curriculum and little emphasis on teamwork. During the intervention period, four simulation sessions occurred per month: two each in the pediatric wards and ED. Resident attendance was optional. Each of the nine teaching modules was conducted four times, for a total of 36 simulation sessions. Each simulation session was 30 min long, consisting of an introduction (review of the simulator and learning contract), resuscitation scenario and debriefing. Debriefings focused on medical management and teamwork learning objectives. One of the two authors (KS or JR) facilitated and debriefed all sessions. Sessions were video-recorded and reviewed for consistency and to assure learning objectives were met periodically throughout the intervention. After each module, all pediatric residents received an aggregate summary of the teams’ performance, highlighting what went well, opportunities for improvement, and a summary of the module’s learning objectives. 2.2.3. Post-intervention test Between August and September 2010, thirty pediatric residents were recruited to form 10 pediatric resident resuscitation teams, as in the pre-intervention test. Post-intervention participation did not require pre-intervention participation. Teams were constructed based strictly on scheduling availability. The post-intervention scenario included a modified patient history and vital signs but contained the same triggers to proceed as the pre-intervention scenario. Residents participated in only one resuscitation team, completed the same experience survey used in the pre-intervention test, a knowledge test and an additional survey about their experience with the standardized curriculum.
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2.2. Study sequence 2.3. Outcome measures
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2.2.1. Pre-intervention test Thirty pediatric residents were recruited to form 10 resuscitation teams. Residents provided written informed consent, completed a survey about previous experience and a 20 question knowledge test. Knowledge test questions came from retired PALS tests. All simulations used a standard set-up, including Laerdal SimBabyTM (Laerdal Corporation, Stockholm, Sweden) and the resuscitation room of the SCH ED. The team was oriented to the environment and provided a scripted clinical vignette. Each team performed one standardized resuscitation. The scenario (a two-year child in shock with subsequent apnea and ventricular fibrillation) was previously piloted. Teams could use cognitive aids, such as PALS algorithm cards. All simulations were facilitated and debriefed by one of the two authors (KS or JR), with standardized responses (e.g. capillary refill time, lab results). Facilitators did not intervene or redirect the team. The scenario was preprogrammed, proceeding based on predetermined times or interventions. Simulations were video-recorded from two angles. One camera provided a wide-angle view of the entire room; the second camera provided an up-close view of the human simulator from directly above. Following each simulation, the resuscitation team was debriefed and completed a questionnaire soliciting feedback about the simulation. Simulations were conducted over 6 weeks. Participants were asked to maintain confidentiality and blinded to the study goals.
The primary outcome measure was difference in overall team performance score on the Simulation Team Assessment Tool (STAT)33 between pre- and post-intervention resuscitation teams. Developed and validated for assessing team performance during a simulated pediatric resuscitation and with good inter-rater reliability, the STAT provides an overall team performance score as well as domain scores for the basics of resuscitation, airway/breathing, circulation and teamwork.33 Secondary outcome measures were differences between the pre- and post-intervention teams on the STAT domains of basics, airway/breathing, circulation and teamwork; differences in knowledge scores; and the impact of team exposure to the new curriculum on overall team STAT performance. 2.4. Raters and scoring All raters were experts in resuscitation, pediatric emergency medicine faculty members at the University of Washington and had participated in a one-time training session as previously described.33 Two raters independently scored each team’s video recorded performance using the STAT.33 Raters viewed pre- and post-intervention videos in arbitrary order without obvious visual clues to identify the timing of the video, in an attempt to remain blinded. Raters were allowed to watch the video recording as many times as necessary to obtain accurate scoring. Discussion was not
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allowed. The average of both raters’ scores was each team’s final score.
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STAT overall performance and domain scores were calculated for each team. The unpaired two-sided T-test was used to analyze differences between the pre- and post-intervention teams’ performance. The impact of group curriculum participation on the STAT overall performance score was analyzed using linear regression including only the post-intervention groups. Since individual experience was categorized as 0 sessions, 1–2 sessions or 3–4 sessions (Table 3), the exact overall number of sessions attended by each team was not retrievable. Instead, 1–2 sessions were counted as 1 “participation point” and 3–4 sessions as 2 points, and the team totals used as the predictor variable. An alternate predictor was the number of members who attended at least one session. Each resident received a knowledge score for both the pre- and post-intervention tests. Unpaired two-sided T-tests were used to analyze the differences between the pre- and post-intervention knowledge.
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Sixty residents participated in the pre- and post-intervention simulated resuscitations. Eight residents participated in both. Preand post-intervention residents did not differ with regard to prior experience with PALS, ACLS, simulation, or participation in mock or real codes. More post-intervention residents took PALS within the previous year (Table 2). Twenty-one of the 30 post-intervention residents (66%) attended at least one of the curriculum’s modules (Table 3). Of the nine that had not, eight were new interns who had limited opportunity to participate in the curriculum. The majority of residents attended modules focused on airway and breathing; few attended circulatory modules. Post-intervention residents who participated in the curriculum rated the modules on a Likert scale (1–5) as realistic, mean score 3.81 (0.81 SD), effective at teaching basic resuscitation skills, mean score 3.9 (0.83 SD), and effective at teaching teamwork skills, mean score 4.48 (0.68 SD). Residents rated the curriculum as important for preparing them to provide pediatric advanced life support, mean score 4.19 (0.98 SD). Resident teams’ post-intervention overall STAT scores were significantly higher than pre-intervention (mean pre-intervention 0.61 (95% CI 0.55, 0.67) vs post-intervention 0.74 (95% CI 0.71, 0.78), p < 0.001) (Table 4 and Fig. 1). STAT domain scores of basics, airway/breathing and teamwork were significantly higher (basic: mean pre-intervention 0.46 (95% CI 0.39, 0.53) vs post-intervention 0.62 (95% CI 0.55, 0.69), p = 0.0016; airway/breathing: mean preintervention 0.63 (95% CI 0.57, 0.69) vs post-intervention 0.76 (95% CI 0.67, 0.85), p = 0.0137; teamwork: mean pre-intervention 0.61 (95% CI 0.51, 0.70) vs post-intervention 0.8 (95% CI 0.72, 0.85), p = 0.0026). In the circulation domain, STAT scores were higher post-intervention than pre-intervention but did not reach statistical significance (mean pre-intervention 0.67 (95% CI 0.57, 0.77) vs post-intervention 0.76 (95% CI 0.72, 0.81), p = 0.075). Residents knowledge test scores did not differ pre- and post-intervention (mean 66.5 vs 68.7, respectively p = 0.308). All post-intervention teams had at least one team member who had participated in the standardized curriculum. One of the teams collectively attended 1–2 modules; five teams 3–4 modules and five teams ≥5 modules. Linear regression analyses conducted on the 10 post-intervention teams, using the overall STAT scores as the outcome and group participation as the explanatory variable,
Table 2 Resident participant characteristics and experience. Pre-intervention N = 30 n (%) Code experience Had ever taken a PALS class Most recent PALS class was within the last year Had ever taken an ACLS class Participated in high-fidelity simulation training in the past Number of previous sessions attended 1–2 3–4 ≥5 Had been active team member in a mock code in the previous 3 years Number of mock codes as a team member 1–2 3–4 ≥5 Number of mock codes as team leader 0 1 2 ≥3 Had been active team member in a real code in the previous 3 years Number of real codes as team member 1–2 3–4 ≥5 Number of real codes as team leader 0 1 2 ≥3
Q5 Post-intervention N = 30 n (%)
29 (97%) 25 (83%)
30 (100%) 30 (100%)*
21 (70%) 30 (100%)
20 (67%) 28 (93%)
10 (33%) 7 (23%) 13 (43%) 28 (93%)
5 (17%) 6 (20%) 17 (57%) 28 (93%)
13 (43%) 6 (20%) 9 (30%)
10 (33%) 6 (20%) 12 (40%)
8 (27%) 9 (30%) 7 (23%) 5 (17%) 20 (67%)
9 (30%) 7 (23%) 5 (17%) 7 (23%) 18 (60%)
12 (40%) 5 (17%) 3 (10%)
6 (20%) 9 (30%) 3 (10%)
14 (47%) 4 (13%) 1 (3%) 0 (0%)
15 (50%) 3 (10%) 0 (0%) 1 (3%)
showed that increased participation was significantly associated with the overall STAT score and teamwork sub-domain and positively associated with remaining sub-domain STAT scores (overall STAT score: score improvement (SE) per curriculum participation point 0.046 (0.012), p = 0.004; basic: 0.034 (0.036), p = 0.37; airway/breathing: 0.057 (0.042), p = 0.22; circulation: 0.024 (0.020), p = 0.28; teamwork: 0.069 (0.024), p = 0.02). 4. Discussion In this study a modular, standardized, simulation-based pediatric resident resuscitation curriculum that included teamwork training was associated with increased residents’ performance scores on a simulated resuscitation in overall performance, basics of resuscitation, airway and teamwork skills. The lack of a significant increase in resident team performance scores for the circulation domain could be due to the small sample size and the smaller number of participants who had attended circulation based modules. Participants reported that the curriculum was realistic and improved their self-efficacy. The curriculum format is consistent with the best practice model for resuscitation education: reduced course duration and distributed practice over time.34 Most follow-up studies of resuscitation performance following a single educational intervention show significant decay in knowledge and skills by 6 months after
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Fig. 1. Pre- and post-intervention test STAT overall scores.
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the course.5,35 However, in our study, residents demonstrated skills developed throughout the year in their post-intervention performance. This supports the model of distributed practice, in addition to traditional resuscitation courses, such as PALS, to mitigate skills decay.
Table 3 Post-intervention resident experience with the standardized resuscitation curriculum, N = 30. n (%) Participated in curriculum by attending at least one teaching session Did not participate in any teaching sessions because were new interns Number of teaching sessions attended 1–2 3–4 ≥5 Teaching modules attended Anaphylaxis Asthma Hypovolemic shock Septic shock Abdominal trauma SVT Head injury Ventricular fibrillation Seizures Airway/breathing modules Circulation modules
21 (70%) 8 (27%)
9 (30%) 12 (40%) 0 (0%) 5 (17%) 5 (17%) 12 (40%) 10 (33%) 4 (13%) 8 (27%) 4 (13%) 2 (7%) 8 (27%) 19 (63%) 12 (40%)
Experience with the curriculum, N = 21 (Likert scale 1–5) Standardized curriculum was realistic Standardized curriculum was effective at teaching basic resuscitation skills Standardized curriculum was effective at teaching code team leadership and behavioral skills Importance of standardized curriculum in teaching you pediatric advanced life support skills
Score (SD) 3.81 (0.81) 3.90 (0.83) 4.48 (0.68) 4.19 (0.98)
Knowledge scores were not impacted by the curriculum. The knowledge of the pediatric residents was high both pre- and postintervention. However, the post-intervention residents were able to translate their knowledge into improved performance on the simulated patient. The use of simulation-based medical education is particularly suited to allow for this translation because simulation-based learning offers deliberate practice.36 Ericsson37 identified the need for deliberate practice to reach expertise and for deliberate practice to include provision of immediate feedback, time for problem-solving and evaluation and opportunities for repeated performance. The curriculum in this study provided opportunities for deliberate practice and capitalized on the features of high-technology simulation to facilitate learning, such as feedback about performance, repetitive practice, progressive difficulty and clinical variation.34 This potentially contributed to the post-intervention residents’ ability to translate their knowledge to performance. The greatest increase in performance scores was in the STAT teamwork domain. It is possible that by improving teamwork skills, teams were more organized, better able to communicate and apply their knowledge, resulting in improved overall performance. Improved teamwork leading to improved clinical performance has been demonstrated in other studies.22–24 In their study on impact of team training of clinical efficacy of trauma resuscitation, Steinemann and colleagues24 demonstrated improved clinical performance in simulated scenarios following team training and, more importantly, continued improved teamwork and clinical performance in real trauma resuscitations 6 months after the training event. Thus, one major impact of our curriculum may be the integration of teamwork training. The fact that performance improved, even if only one team member experienced the curriculum, suggests an inoculation effect: only a small number of team members needed exposure to improve the care of the simulated patient. In addition, we observed a dose–response relationship – those participants with repeated exposure to the curriculum had increased performance scores in the post-intervention group. McGaghie and colleages38 reported
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Q6 Pre and post-intervention STAT overall and domain scores.
STAT score Basic score Airway score Circulation score Teamwork score a
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314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359
Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI] Mean (SD)[95% CI]
Pre intervention N = 10
Post intervention N = 10
Pre to post changes mean (95% CI)
p-Valuea
0.609 (0.088)[0.55, 0.67] 0.456 (0.098)[0.39, 0.53] 0.627 (0.081)[0.57, 0.69] 0.669 (0.143)[0.57, 0.77] 0.606 (0.134)[0.51, 0.70]
0.744 (0.054)[0.71, 0.78] 0.621 (0.101)[0.55, 0.69] 0.756 (0.125)[0.67, 0.85] 0.765 (0.061)[0.72, 0.81] 0.785 (0.091)[0.72, 0.85]
0.135 (0.067, 0.204) 0.164 (0.071, 0.258) 0.128 (0.03, 0.227) 0.096 (−0.011, 0.203) 0.179 (0.071, 0.287)
0.0006** 0.0016** 0.0137* 0.0750 0.0026**
p-Value is for the comparison of STAT scores between post-intervention and pre-intervention.
a similar dose-response relationship following simulation-based learning with increasing hours of simulation-based practice leading to improved outcomes. Together the findings of a possible inoculation effect and a dose–response relationship suggest additional benefits of the curriculum leading to improved performance in the simulation resuscitation and potentially future areas of study.
5. Limitations Inherent in the pre- and post-intervention study design is whether observed results are due to the intervention. We are unaware of any additional systematic or educational changes during the intervention period regarding pediatric resuscitations that would have affected our results. It is also possible that the natural progression of skills impacted the results. We attempted to control for this by conducting the testing sessions at the same point in the academic year. The similar number of pre- and post-intervention residents who participated in mock or real resuscitations suggests that increased exposure to resuscitations alone would not explain these findings. Our intervention reached only a subset of all pediatric residents, as shown in Table 3. Participation may have been limited by competing clinical or educational demands. This is realistic for and comparable to other educational interventions. However, we would expect limited exposure to result in lower performance scores instead of the observed increased performance scores. It is possible that the eight residents who participated in both the pre- and post-intervention tests could skew the results if they recognized the scenario. However, in a multi-center study where participants were exposed to a similar simulation scenario at intervention, 3 and 6 months follow-up, there was no demonstrated improvement,39 arguing against participants ability to recognize similar scenarios. Selection bias may be present among the post-intervention test residents. Those who participated in the curriculum, felt it was useful, or became more confident or skilled, may have been more likely to participate in the post-intervention test. In addition, residents teams were created solely based on resident availability, due to scheduling challenges. The distribution of more experienced residents may not have been equivalent. Either of these could have potentially influenced their scores. This study was conducted in one institution, testing one resuscitation scenario, with a small number of faculty facilitators. Further study is needed to identify the reproducibility of the curriculum and elucidate the highest impact components of the curriculum on team performance. Next steps include incorporating this curriculum into other residency programs and refining the content for maximal performance improvement. Finally, the STAT was validated for use in simulated pediatric resuscitation; however, there has been no correlation of STAT performance with clinical performance or patient outcomes. Therefore, the meaning of an individual STAT score requires consideration. Ultimately, the challenge remains to demonstrate that improved performance in simulation translates to improvement in clinical pediatric resuscitations.
6. Conclusion We created a modular, standardized, simulation-based pediatric resuscitation curriculum with distributed practice over time that was well received by residents and associated with increased scores in pediatric residents’ medical management and teamwork skills in a simulation setting, in a dose-related response. Funding This study was supported by the Academic Enrichment Fund from the Department of Pediatrics, University of Washington Q4 School of Medicine. The funding source had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. Conflict of interest statement None of the authors have any conflicts of interest to declare. Acknowledgements We wish to thank The Learning and Simulation Center at Seattle Children’s Hospital who helped with all technical aspects of this project. We also thank Assaf Oron, PhD from Seattle Children’s Research Institute who provided valuable statistical input. References 1. White JRM, Shugerman R, Brownlee C, Quan L. Performance of advanced resuscitation skills by pediatric housestaff. Arch Pediatr Adolesc Med 1998;152:1232–5. 2. Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DRM. Assessing pediatric senior residents’ training in resuscitation: fund of knowledge, technical skills, and perception of confidence. Pediatr Emerg Care 2000;16:73–6. 3. Hunt EA, Patel S, Vera K, Shaffner DH, Pronovost PJ. Survey of pediatric resident experiences with resuscitation training and attendance at actual cardiopulmonary arrests. Pediatr Crit Care Med 2009;10:96–105. 4. Accreditation Council for Graduate Medical Education, Outcome project: Common Program Requirements – General Competencies, 2007. 5. Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Teaching resuscitation to pediatric residents: the effects of an intervention. Arch Pediatr Adolesc Med 2000;154:1049–54. 6. Quan L, Shugerman RP, Kunkel NC, Brownlee CJ. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course. Pediatrics 2001;108:e110. 7. Tofil NM, White ML, Manzella B, McGill D, Zinkan L. Initiation of a pediatric mock code program at a children’s hospital. Med Teach 2009;31:e241–7. 8. Friedman D, Zaveri P, O’Connell K. Pediatric mock code curriculum: improving resident resuscitations. Pediatr Emerg Care 2010;26:490–4. 9. Barsuk D, Ziv A, Lin G, et al. Using advanced simulation for recognition and correction of graps in airway and breathing management skills in prehospital trauma care. Anesth Analg 2005;100:803–9. 10. Marshall RL, Smith JS, Gorman PJ, Krummel TM, Haluck RS, Cooney RN. Use of a human patient simulator in the development of resident management skills. J Trauma 2001;51:17–21. 11. Hammond J. Simulation in critical care and trauma education and training. Curr Opin Crit Care 2004;10:325–9. 12. Mayo PH, Hackney JE, Mueck JT, Ribaudo V, Schneider RF. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med 2004;32:2422–7.
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