Review 259

Simulation-Based Neonatal and Infant Resuscitation Teaching: A Systematic Review of Randomized Controlled Trials

Authors

L. P. Mileder1, 2, B. Urlesberger2, E. G. Szyld3, C. C. Roehr4, 5, 6, 7, G. M. Schmölzer2, 8, 9

Affiliations

Affiliation addresses are listed at the end of the article

Key words ▶ newborn ● ▶ infant ● ▶ resuscitation ● ▶ education ● ▶ simulation ● ▶ systematic review ●

Abstract

Zusammenfassung

Background: Current resuscitation guidelines recommend the use of simulation-based medical education (SBME) as an instructional methodology to improve patient safety and health. We sought to investigate the evidence-base for the effectiveness of SBME for neonatal and pediatric resuscitation training. Method: Therefore, we conducted a systematic literature research of electronic databases (PubMed, EMBASE, Clinical Trials). Results: 13 randomized controlled trials with a total of 832 participants were identified. However, due to distinct differences in research objectives and varying outcome assessment a meta-analysis of studies could not be conducted. Eligible trials showed that SBME can enhance trainees’ cognitive, technical, and behavioral skills as well as self-confidence. Discussion/Conclusion: Skills acquired in the simulated environment can be integrated in clinical practice, and SBME might also lead to improved patient safety and health. Further research on SBME – especially investigating patient outcomes – is urgently required in order to strengthen these results and to establish a sound evidence-base for the effectiveness of SMBE for neonatal and infant resuscitation training.

Hintergrund: Aktuelle Reanimationsrichtlinien empfehlen die Nutzung von simulationsbasierter Ausbildung zur Verbesserung von Patientensicherheit und -gesundheit. Wir untersuchten die Evidenz für die Effektivität simulationsbasierter Ausbildung in der Neugeborenen- und Kinderreanimation. Methode: Wir führten eine systematische Literaturanalyse in elektronischen Datenbanken (PubMed, EMBASE, Clinical Trials) durch. Ergebnisse: 13 randomisierte kontrollierte Studien mit einer Gesamtteilnehmerzahl von 832 wurden gefunden. Aufgrund ausgeprägter Unterschiede bei Fragestellungen und Auswertemodalitäten konnte keine Meta-Analyse der Studien durchgeführt werden. Die Studien zeigten, dass simulationsbasierte Ausbildung kognitive, technische und verhaltensbezogene Fertigkeiten ebenso wie Selbstbewusstsein der Trainingsteilnehmer positiv beeinflussen kann. Diskussion/Schlussfolgerung: In einem simulierten Umfeld erworbene Fertigkeiten können in die klinische Tätigkeit umgesetzt werden, und simulationsbasierte Ausbildung kann darüber hinaus zu verbesserter Patientensicherheit und -gesundheit führen. Weitere Untersuchungen zu simulationsbasierter Ausbildung – insbesondere in Bezug auf das Patienten-Outcome – sind dringend erforderlich, um diese Ergebnisse zu untermauern und eine solide Evidenz für die Effektivität in Zusammenhang mit Neugeborenen- und Kinderreanimation zu etablieren.

Abbreviations

Background

HALO NRP PALS RCT SBME

A retrospective analysis of 47 cases of perinatal death and permanent disability reported to the Joint Commission on Accreditation of Healthcare Organizations showed that more than two thirds could be attributed to insufficient or ineffective

Schlüsselwörter ▶ Neugeborenes ● ▶ Kind ● ▶ Reanimation ● ▶ Ausbildung ● ▶ Simulation ● ▶ Systematischer Review ●

Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1372621 Klin Padiatr 2014; 226: 259–267 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Dr. 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]









– High acuity, low occurrence – Neonatal Resuscitation Program – Pediatric advanced life support – Randomized controlled trial – Simulation-based medical education

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

Simulationsbasierte Ausbildung in der Reanimation von Neugeborenen und Kindern: Ein systematischer Review randomisierter kontrollierter Studien

260 Review

titles and abstracts for potential eligibility and full texts for final ▶ Fig. 1). When discrepancies arose, a third party eligibility (● (BU) was consulted. Data were extracted using a standardized data collection form to record study design and methodological characteristics, patient characteristics, interventions, primary/secondary outcomes, and missing outcome data. Authors of included trials were contacted for additional information not described in the published reports.

Risk of bias assessment The Cochrane Collaboration’s risk of bias tool (sequence generation, allocation concealment, blinding of participants, personnel and outcome, incomplete outcome data, selective outcome ▶ Table 1) was used for risk of bias assessment [21]. reporting; ● We further evaluated the possibility of funding bias, institutional review board approval, informed consent, sample size calculation, availability of CONSORT flow diagram, and trial registration.

Results



▶ Table 1). Participants of 13 RCTs met our selection criteria (● included studies consisted of medical students, nurses, interns, residents, and multidisciplinary healthcare teams, with a total number of 832 enrolled participants [4–7, 9–11, 26, 29, 44, 52, 53, 57]. We planned to perform a meta-analysis on the impact of SBME in the context of neonatal and infant resuscitation. Although our search identified 13 RCTs, we were unable to combine any in a meta-analysis due to heterogeneous research objectives, different outcome measures, and varying outcome assessment. Therefore, we present our findings stratified by study interventions.

Simulation vs. non-simulation instruction Method



Eligibility criteria Studies investigating the educational effect of SBME using lowand/or high-fidelity mannequins for neonatal and/or infant resuscitation training were eligible for inclusion. Trials comparing low- to high-fidelity simulation as resuscitation training methods were also included.

Data sources and search strategy We searched Medline via PubMed (January 1965–December 2013) and EMBASE (1988–December 2013) using the following MeSH database terms: “Education”, “Resuscitation”, “Infant”, and “Infant, Newborn”. “Simulation” was used as additional search term. The electronic database search was limited to randomized controlled trials (RCTs) with no language restrictions. We also searched ClinicalTrials.gov for completed and ongoing trials using similar search terms. Further, we reviewed abstracts from the Pediatric Academic Societies’ annual meetings (2000–2013), and performed a manual search of references in narrative and systematic reviews on neonatal and infant simulation. The search strategies for PubMed and EMBASE are detailed in Appendix 1.

Study selection and data collection process The standard protocols of the Cochrane Neonatal Review Group were applied. 2 authors (LPM, GMS) independently screened

3 RCTs including medical students, residents, and postpartum nurses compared SBME with other instructional methodologies ▶ Table 1). (● Cavaleiro et al. [6] compared self-study vs. simulation-based training in 45 5th-year medical students. Following a theoretical lecture, students were randomized to either receive a low-fidelity simulation session or to self-study. Students’ knowledge was assessed by using multiple-choice tests i) prior to the introductory lecture, ii) before being randomized, and iii) after the resuscitation simulation or self-study session. Although test scores significantly improved after the lecture, neither simulation nor self-study further increased students’ theoretical neonatal resuscitation knowledge. Lee et al. [29] studied the impact of a simulation-based neonatal training session on emergency medicine residents’ competency. Residents in the control group received the hospital’s standard emergency medicine residency curriculum featuring weekly educational conferences, monthly simulation sessions, and monthly pediatric lectures. Participants randomized into the intervention group received an additional 4-hour educational intervention including Neonatal Resuscitation Program (NRP) algorithm review, practical skills training, and high-fidelity simulation on top of the standard training. Baseline resuscitation performance scores were similar within groups. Compared to the control group, participants of the intervention group i) had significantly improved performance scores at the final

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

team communication [25]. Hence, it has been suggested to conduct drills for high-risk events such as neonatal resuscitation to prepare clinical staff [25]. In accordance with this report by the Joint Commission on Accreditation of Healthcare Organizations, current resuscitation guidelines recommend utilizing simulation as an instructional methodology for neonatal and infant resuscitation training [43, 50]. Simulation, which originated from aviation and space flight training programs, was adopted by anesthesiologists as early as in the 1960s, which eventually led to the development of simulationbased medical education (SBME) [1, 16, 23, 48]. Simulation is based on deliberate practice, reflection, and feedback, and defined as “the controlled representation of real world phenomena, used when real world experiences are either unavailable or undesirable” [31, 49]. For SBME, the concept of deliberate practice is of particular interest as it focuses on achieving and maintaining expert performance and requires – among other factors – highly motivated learners, a well-defined learning objective, and repetitive practice [36]. SBME utilizes i) verbal role playing, ii) standardized patients (actors), iii) part-task trainers, iv) computer patients (screen-based ‘virtual world’), v) electronic patients (mannequinbased), vi) live animals, and vii) human corpses [8, 15]. It facilitates structured, controlled and risk-free learning, allows on-demand training, and offers reproducibility of learning experiences; furthermore, SBME combines cognitive, technical, and behavioral skill acquisition and enables multidisciplinary team training [14, 19, 20, 31, 56]. In addition, clinical performance can be accurately assessed by using simulation [46]. Although current resuscitation guidelines recommend SBME, the supporting evidence is scarce. Therefore, the aim of the article was to review the available literature about simulation-based neonatal and infant resuscitation training and specifically its impact on i) individual and team performance and ii) patient outcomes.

Review 261

Fig. 1 PRISMA flow chart. Trials identified through electronic databases (PubMed, Embase): n = 143

Trials identified through other sources (ClinicalTrials.gov, PAS-Abstracts, reference lists): n = 10

Articles after removing duplicates: n = 136

Articles screened on basis of title and abstract: n = 136

Articles excluded: n = 119

Full-text articles assessed for eligibility: n = 17

Articles excluded: n = 4 Unsuitable study question/outcomes: 3 Concerns with study design: 1

Articles included in qualitative analysis: n = 13

assessment, ii) were significantly more efficient in completing critical actions (e. g. warming and drying, mask ventilation, intubation, chest compressions), and iii) had significantly improved neonatal resuscitation confidence levels. Weiner et al. [57] randomly assigned nurses to self-directed learning with low-fidelity simulation vs. traditional NRP training. Self-directed learning included a textbook, instructional video, simple mannequin, and resuscitation equipment for course preparation; instead of the standard NRP, participants completed a 90-minute simulation session with 3 low-fidelity trainings and debriefings. After course completion, all participants were tested on a high-fidelity simulator. No differences in resuscitation performance scores or knowledge were identified between groups. Nurses in both groups were equally satisfied with their respective courses.

Simulation fidelity We identified 4 RCTs which directly compared various degrees ▶ Table 1). The studies included residents of simulation fidelity (● and interprofessional healthcare teams. Campbell et al. [5] randomly allocated family medicine residents to either a high- or a low-fidelity mannequin during an NRP course. Residents in the high-fidelity group had a trend to

greater improvement in written examination scores (pre- vs. post-training) and shorter times to intubation. As educational experience, high-fidelity simulation was rated significantly higher compared to low-fidelity training. In the multicenter trial by Cheng et al. [7], interprofessional healthcare teams (each including nurses, physicians, respiratory therapists or paramedics) participated in 2 cardiopulmonary arrest scenarios. Participants were randomized to one of 4 study groups, consisting of permutations of scripted vs. non-scripted debriefing and high- vs. low-fidelity simulators. Multiple-choice tests were used to assess individual knowledge before and after the intervention, while pediatric advanced life support (PALS) team performance and behavior of team leaders during simulation training were assessed through video review. Both nonscripted and scripted debriefing led to improvements in all 3 outcome measures; however, participants receiving scripted debriefing showed greater improvement in knowledge and team leader performance. Participants of both high- and low-fidelity simulation showed improved knowledge, clinical performance, and team leader behavioral scores after the debriefing, but the simulator’s physical realism did not have an independent, statistically significant effect on any outcome measures.

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

Adult resuscitation/trauma care: 57 Equipment/technology evaluation: 44 Other reasons: 18

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

nurses from postpartum wards

residents

interprofessional healthcare teams

residents

Weiner et al. [57]

Campbell et al. [5]

Cheng et al. [7]

Donoghue et al. [10] Donoghue et al. [11]

residents

SBT with (n = 16) or without cognitive aid (n = 16)

generation

Sequence

low

unclear

Cognitive aid resuscitation performance, completion of life-saving interventions, ANTS score

teamwork, resuscitation performance, resuscitation duration

response time to life-saving steps, number of intubation attempts, self-confidence Teamwork training teamwork behavior

low

low

low

low

Downloaded by: University of Pittsburgh. Copyrighted material.

low

unclear

unclear

unclear

low

low

low

unclear

low

unclear

unclear

unclear

unclear

high

low

high

low

low

unclear

unclear

unclear

unclear

low

low

low

unclear

unclear

low

unclear

unclear

low

high

unclear

unclear

low

unclear

low

unclear

low

low

low

low

low

low

unclear

low

low

low

unclear

low

low

low

unclear

unclear

unclear

low

unclear

unclear

unclear

unclear

unclear

unclear

unclear

unclear

unclear

reporting

data

and outcome

ment unclear

bias

outcome

outcome

pants, personnel

unclear

Funding

Selective

Incomplete

Blinding of partici-

conceal-

Allocation

low

subjective realism of scenarios, physical unclear features contributing most to realism Knowledge and skill retention unclear resuscitation performance, theoretical knowledge, self-confidence, satisfaction after 0, 4 and 8 months theoretical knowledge, skill performance unclear after 6–8 months

cognitive task performance

Simulation fidelity NRP test scores, checklist performance, time required for task performance, number of redirections, satisfaction individual knowledge, team performance, team leader behavior

resuscitation performance, self-confidence, number of critical actions, time to critical steps resuscitation performance, theoretical knowledge, satisfaction, self-confidence

Simulation vs. non-simulation instruction theoretical knowledge unclear

Outcome measures

SBT: Simulation-based training; NRP: Neonatal Resuscitation Program; ANTS: Anesthetists’ Non-Technical Skills; PALS: Pediatric advanced life support

Bould et al. [4]

interns

standard NRP (n = 15) vs. NRP with human error curriculum (n = 17) standard NRP (n = 36) vs. NRP with team training (n = 31) vs. NRP with high-fidelity simulation and team training (n = 31)

resuscitation proficiency 4 months (n = 12) vs. 8 months after SBT (n = 12)

residents

interns

NRP update by mannequin training (n = 14) vs. video (n = 13) vs. control (n = 17)

residents

Kaczorowski et al. [26] Roy et al. [44]

Thomas et al. [52] Thomas et al. [53]

NRP update by high-fidelity simulation (n = 16) vs. video (n = 15)

medical students

NRP: Megacode training with high-fidelity simulator (n = 8) vs. low-fidelity mannequin (n = 7) non-scripted debriefing, low-fidelity simulator (n = 97) vs. scripted debriefing, lowfidelity simulator (n = 93) vs. non-scripted debriefing, high-fidelity simulator (n = 103) vs. scripted debriefing, high-fidelity simulator (n = 94) PALS training with high-fidelity simulator (n = 25) vs. standard mannequin (n = 26) PALS training with high-fidelity simulator (n = 25) vs. standard mannequin (n = 26)

standard emergency medicine curriculum (n = 15) vs. standard curriculum with SBT (n = 12) self-directed learning and low-fidelity simulation (n = 23) vs. traditional NRP (n = 23)

self-study (n = 21) vs. SBT (n = 24)

Comparison

Curran et al. [9]

residents

medical students residents

population

Study

Cavaleiro et al. [6] Lee et al. [29]

Study

Table 1 Risk of bias assessment of randomized controlled trials investigating simulation-based neonatal and infant resuscitation teaching.

262 Review

Review 263

Knowledge and skill retention 3 RCTs including medical students and residents investigated ▶ Table 1). knowledge and skill retention after SBME (● Curran et al. [9] investigated the effectiveness of a high-fidelity newborn patient simulator (ANAKIN) to update and assess neonatal resuscitation skills in 31 3rd-year medical students. Neonatal resuscitation skills were assessed immediately after an NRP course and at 4- and 8-month intervals. At the 4-month interval, students were randomly assigned to either receive an NRP tutorial using the ANAKIN system or to watch an NRP instructional video as booster strategy. After the 8-month period all students completed a megacode session using the ANAKIN simulator. Participants’ resuscitation performance, knowledge, confidence, and general satisfaction were assessed. Overall, students’ theoretical knowledge and resuscitation performance significantly deteriorated over the 8-month-period. Both approaches were equally effective for maintenance of neonatal resuscitation skills and resulted in a similar increase in students’ confidence scores. In addition, 75 % of the participants agreed that the simulation experience had prepared them better to deal with a future neonatal emergency. Kaczorowski et al. [26] compared 2 booster strategies (video vs. simulation-based training) vs. a control group for retention of neonatal resuscitation knowledge and skills in family medicine residents after an NRP course. Overall, knowledge and skill levels decreased significantly in all groups at the follow-up assessment at 6–8 months after the initial course. Promising was the fact that residents in the hands-on training group made significantly fewer performance errors in life-supporting skills during the follow-up assessment. Roy et al. [44] assessed proficiency and retention of skills in pediatric residents after an initial training course featuring lectures, skills workshops, and various simulated clinical scenarios. Participants were randomized to be retested 4 or 8 months after the initial training. Residents evaluated after 4 months reacted faster to apnea or pulselessness, and initiated mask ventilations and chest compressions significantly faster. Overall, comfort levels in managing pediatric emergencies increased significantly for both groups after the simulation-based course and 83 % of the residents stated that high-fidelity simulation training should become an integral part of their education.

Teamwork training 2 RCTs involving interns studied the impact of teamwork train▶ Table 1). ing (●

Thomas et al. [52] evaluated the effect of a human error curriculum on teamwork behavior during simulated resuscitations, using lectures, role plays, videos, and a question-and-answer session as part of an NRP course. Interns allocated to team training demonstrated team behavior significantly more often, more frequently, and for a longer period of time compared to the control group. A further study by Thomas et al. [53] evaluated the effect of teamwork training during an NRP course on team behavior and the quality of simulated resuscitations. Interns randomized into the control group received standard NRP training, compared to either additional 2-hour team training or high-fidelity simulation and team training. Although teamwork event rates were significantly higher in the high-fidelity group, resuscitation performance was similar within groups. Duration of resuscitation was reduced by one quarter in intervention groups compared to controls. A reassessment 6 months after the initial course showed no differences in resuscitation performance.

Cognitive aid One RCT, investigating the impact of a cognitive aid, met our ▶ Table 1). selection criteria (● Bould et al. [4] randomized 32 anesthesiology residents to either have a cognitive aid (a poster detailing current neonatal resuscitation guidelines) available vs. no cognitive aid during a simulation scenario. The study reported no differences in resuscitation performance and Anesthetists’ Non-Technical Skills scores between groups.

Discussion



Approximately one million newborn infants die annually due to birth asphyxia [28]. In addition, 10 % of neonates require respiratory assistance at birth and < 1 % require intensive resuscitation [43]. Referring to the relative infrequency of pediatric emergencies, Weinstock et al. [58] coined the term ‘pediatric training paradox’, which describes the risk of clinicians being “unprepared, hesitant, and highly anxious” due to the lack of practical learning experiences. SBME offers important advantages to reach proficiency in ‘high acuity, low occurrence’ (HALO) situations which arise infrequently but still require a high level of cognitive and technical competency as well as mental preparedness [10], and neonatal and infant resuscitation perfectly meet the description of such HALO events [19]. Our systematic review was limited by the lack of evidence. Although we identified 13 eligible RCTs, we were unable to perform any meta-analysis due to variability in study interventions and outcome measures.

Simulation vs. non-simulation instruction Several trials compared simulation-based training with other educational methodologies. Cavaleiro et al. [6] reported no differences in students’ theoretical knowledge gain about neonatal resuscitation after simulation-based training vs. self-study. In the study by Lee et al. [29], a single simulation-based training significantly improved residents’ resuscitation performance and confidence levels. The control group, which received the standard residency training, experienced a decrease in resuscitation proficiency and generally poor self-efficacy. Weiner et al. [57] proved that self-study with a simple mannequin and low-fidelity

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

Donoghue et al. [10] used a high-fidelity patient simulator which was either activated or disabled to teach 51 residents PALS. Each group had to complete 3 study phases: i) 4 simulation scenarios to assess baseline performance, ii) review of PALS algorithms, and iii) final assessment using 2 scenarios focusing on the same set of tasks as the initial training session. Baseline performance scores were similar in both groups. The mean final scores were higher in the high-fidelity group and, in addition, the improvement between the first and second simulation training was significantly increased in the intervention group. In a further study, Donoghue and colleagues [11] assessed realism of PALS scenarios. Participants in the high-fidelity group rated all 6 scenarios more realistic. Chest wall movement and palpable pulses were the features viewed to contribute most to the degree of realism.

264 Review

Simulation fidelity Suspension of disbelief is required for effective and educationally valuable simulation-based training [20]. Regarding the degree of realism, 3 categories of simulation fidelity have to be differentiated: i) equipment or biological fidelity, referring to the patient simulator’s capability of replicating reality (low vs. high), ii) environmental or physical fidelity, describing the realism of the training site, and iii) psychological fidelity or “the degree to which the trainee perceives the simulation to be a believable representation of the reality it is duplicating” [14, 19]. PALS training with a high-fidelity patient simulator leads to significantly better improvement in clinical performance compared to standard mannequin training [10]. In the study by Campbell et al. [5], residents using a high-fidelity simulator during NRP training had higher increases in written examination scores and intubated sooner compared to participants using a low-fidelity mannequin, although this was not statistically significant. In addition, residents in the high-fidelity group needed fewer redirections from instructors, which could implicate a more realistic and immersive educational experience [5]. Overall, both high- and low-fidelity simulation result in performance improvement [7]. However, McGaghie et al. [35] described a dose-response-like correlation between the amount of practice hours and learning outcomes only for high-fidelity simulator training. Hence, as this topic is of major relevance for medical educators, more and larger trials are needed to identify which degree of simulation fidelity is most effective and translates into improved clinical performance.

Knowledge and skill retention The study by Bould et al. [4] showed that none of 32 NRP certified residents performed all life-saving steps correctly during simulated resuscitations; hence, none would have received certification 17 months after NRP training. Accordingly, 3 trials showed significant deterioration of resuscitation knowledge and skills over a 4- to 8-month period [9, 26, 44]. In contrast, Wayne et al. [55] demonstrated that advanced cardiac life support skills did not decrease over 14 months after 4 initial 2-hour simulator trainings. Another study showed that interns were highly proficient during actual clinical emergencies over a 10-month follow-up period after participating in an airway management training involving a patient simulator [32]. Although the problem of skill and knowledge deterioration is well known, optimal booster strategies and training intervals for cognitive and technical skills have not been identified yet [9, 17, 26, 44]. The challenge of maintenance of competency is further complicated as skills deteriorate faster than knowledge [42].

Teamwork training It has been recommended to conduct i) team-based training sessions in perinatal areas, and ii) clinical drills followed by debriefings in order to reduce perinatal mortality and morbidity [25]. Principles of crew/crisis resource management can be ideally practiced through simulation to improve teamwork and com-

munication [22, 56]. 2 studies in our review clearly showed that the implementation of behavioral skills training leads to significantly improved teamwork [52, 53], which is supported by further research [59]. Multidisciplinary crew/crisis resource management training may result in a significant decrease in clinical error rate [38]. By reducing the incidence of medical errors and potentially improving patient safety, teamwork and communication training might ultimately be one of the greatest benefits of SBME.

Impact of SBME McGaghie et al. [33] proposed 3 levels (T1–T3) to grade the impact of SBME research. T1 studies focus on learning outcomes in a controlled, simulated environment. Level T2 research evaluates the transfer of knowledge or skills from the educational laboratory to patient care. The outcome measurement of T3 research is improvement in patient or public health [18, 33]. The majority of trials in our review demonstrated that SBME improved knowledge, skills, confidence, and attitude in simulated environments [5, 7, 9, 10, 26, 29, 44, 53, 57]. However, trainees’ self-reported confidence is a confounding outcome measure as it does not necessarily correlate with actual clinical competency [9, 54]. In comparison, training in the skills laboratory correlates with improvement in technical skills [8, 30, 34]. After participation in a resuscitation course with practical skills training and mock resuscitations, pediatric residents performed technical skills significantly better and had a reduced clinical error rate compared to traditionally trained colleagues [39]. Kory et al. [27] reported that residents who had received training on a patient simulator performed 8 out of 11 airway management steps significantly better than traditionally trained residents despite 2 years of residency experience. Deficiencies in clinical training were concerning as all residents in the control group failed to successfully complete the essential initial airway management tasks. Our review did not identify any studies focusing on T2 outcomes. However, there is growing evidence showing that skills acquired and practiced in the simulation laboratory can be successfully transferred into patient care. Barsuk et al. [3] compared traditional training (“see one, do one”) in central venous catheterization with simulation-based training. Simulator-trained residents performed significantly better in real patients with higher success rates, fewer skin punctures, and a lower number of arterial punctures compared to the control group. In a randomized trial, Schroedl et al. [47] compared simulation-based education focusing on circulatory shock, respiratory failure, and mechanical ventilation with standard residency training (formal and bedside teaching); residents in the intervention group scored significantly higher on a bedside skills assessment, with training status being a significant predictor of skills performance. Despite our systematic literature analysis, we were unable to identify any RCTs addressing level T3 study questions, although a number of neonatal, pediatric, and obstetric studies have reported that SBME can improve patient safety and health. Patel et al. [41] analyzed newborn health in 636,429 high-risk deliveries and found a significant decrease in low 1- and 5-minute Apgar scores after NRP implementation. Very-low-birth-weight and low-birth-weight infants benefited the most from NRP, rendering SBME a possible strategy to decrease mortality and morbidity among preterm newborns [45, 51]. However, this has to be interpreted with caution as the Apgar score is an unreliable predictor of patient outcome and subject to interobserver

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

simulation sessions were equally effective compared to the standard NRP course in regard to nurses’ megacode performance, cognitive skills, and self-confidence, despite significantly shorter course duration in the intervention group. In addition, 2 trials demonstrated that using mannequin training was as effective for neonatal resuscitation knowledge and skill retention as watching a training video [9, 26].

Review 265

Suggestions regarding SBME SBME has been widely adopted and implemented in nursing, allied health, as well as in undergraduate, graduate, and postgraduate medical training [24, 56]. Our systematic review revealed no negative effects associated with SBME, which is consistent with other findings [43]. SBME can increase trainees’ selfconfidence, knowledge, technical skills, and team behavior. In addition, SBME might also improve clinical performance as well as patient safety and health. Based on the results of our qualitative literature analysis, highfidelity simulation training seems to be associated with additional educational benefits compared to low-fidelity training. However, costs of high-fidelity patient simulators are significant and the main reason for institutions not to implement simulation-based training [37]. For institutions with limited resources, utilization of simulation equipment of lower technical fidelity, sharing simulators and facilities with other healthcare institutions, or implementation of e-learning and screen-based simulation represent options for cost-efficient, yet effective training [37]. Our study emphasized the need for more studies to assess knowledge and skill retention. While SBME consistently leads to improved performance initially after training, both cognitive and technical skills significantly deteriorate within months. Although the optimal frequency for refresher training is unclear, evidence suggests performing at least biannual training to ensure maintenance of knowledge and skills. This literature review revealed a distinct lack of RCTs focusing on i) patient outcomes and ii) most effective instructional design features in SBME. Therefore, future RCTs should specifically focus on T3 study questions and try to determine the effectiveness of various instructional designs including repetitive practice, mastery learning, or team training.

Conclusion



Neonatal and infant resuscitation guidelines recommend SBME as an essential part of resuscitation training. However, there is a lack of high-quality empirical evidence regarding SBME for neonatal and infant resuscitation, suggesting that these recommendations have not been extensively implemented in clinical practice. Current recommendations are based on single pediatric trials and on studies involving other medical specialties. Future RCTs should investigate the effect of dedicated simulation-based neonatal and infant resuscitation training on practitioners’ competency and in particular on patient outcomes. In addition, further research should focus on specific instructional design features in SBME, e. g. the impact of simulation fidelity.

Acknowledgements



Charles C. Roehr gratefully acknowledges the generous support of the European Respiratory Society (ERS) and the ERS longterm research fellowship LTFR n °15-2011. Georg M. Schmölzer is recipient of a Banting Postdoctoral Fellowship, Canadian Institute of Health Research, and an Alberta Innovate-Health Solution Clinical Fellowship. The authors thank Simone Dold for improving the manuscript.

Conflict of interest: Lukas 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. Affiliations Clinical Skills Center, Medical University of Graz, Graz, Austria 2 Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria 3 Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York, United States of America 4 Department of Neonatology, Charité, Universitätsmedizin Berlin, Berlin, Germany 5 Neonatal Research Unit, The Royal Women’s Hospital, Melbourne, Australia 6 The Ritchie Centre, Monash University, Melbourne, Australia 7 Dieter Scheffner Fachzentrum für medizinische Hochschullehre und evidenzbasierte Ausbildungsforschung, Charité, Universitätsmedizin Berlin, Berlin, Germany 8 Department of Pediatrics, University of Alberta, Edmonton, Canada 9 Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada 1

References

Limitations and strengths Our study has certain limitations. As it is the case with any systematic literature review, the number and quality of included studies determine the strength of the conclusions. In our case, heterogeneity of research objectives, educational interventions, outcome measures, and outcome assessment rendered the planned meta-analysis impossible, which limits generalizability of our results. We focused our literature review on simulation-based neonatal and infant resuscitation training. To our knowledge, this is the first systematic review on this topic. The broad scope certainly is a strength, but also contributed to between-study heterogeneity. Additional strengths of our review include the systematic, comprehensive literature search and data collection, the focus on randomized controlled studies, and rigorous risk of bias assessment.

1 Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. J Med Educ 1969; 44: 515–519 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 Barsuk JH, McGaghie WC, Cohen ER et al. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med 2009; 37: 2697–2701 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 Campbell DM, Barozzino T, Farrugia M et al. High-fidelity simulation in neonatal resuscitation. Paediatr Child Health 2009; 14: 19–23 6 Cavaleiro AP, Guimarães H, Calheiros FL. Training neonatal skills with simulators? Acta Paediatr 2009; 98: 636–639 7 Cheng A, Hunt EA, Donoghue A et al. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr 2013; 167: 528–536 8 Cook DA, Hatala R, Brydges R et al. Technology-enhanced simulation for health professions education – a systematic review and metaanalysis. JAMA 2011; 306: 978–988

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

variability [40]. In another trial, simulation-based mock codes for pediatric resuscitation teams resulted in significantly improved survival rates, correlating with the increasing number of mock codes [2]. Draycott et al. [12] reported that training of shoulder dystocia management on a birthing mannequin significantly reduced neonatal injury at birth. A further study showed that the incidence of infants with hypoxic-ischemic encephalopathy decreased significantly after the introduction of a simulation-based obstetrical emergency training [13].

9 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 10 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 11 Donoghue AJ, Durbin DR, Nadel FM et al. Perception of realism during mock resuscitations by pediatric housestaff: the impact of simulated physical features. Simul Healthc 2010; 5: 16–20 12 Draycott TJ, Crofts JF, Ash JP et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112: 14–20 13 Draycott T, Sibanda T, Owen L et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006; 113: 177–182 14 Fritz PZ, Gray T, Flanagan B. Review of mannequin-based high-fidelity simulation in emergency medicine. Emerg Med Australas 2008; 20: 1–9 15 Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004; 13: i2–i10 16 Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology 1988; 69: 387–394 17 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 18 Griswold S, Ponnuru S, Nishisaki A et al. The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives. Pediatr Clin North Am 2012; 59: 1329–1340 19 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 20 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 21 Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies, Cochrane handbook for systematic reviews of interventions, Version 5.1.0. Edited by Higgins JP T, Green S. The Cochrane Collaboration. 2011 Available at: http://www.cochrane-handbook.org [Accessed November 14, 2012] 22 Hunt EA, Shilkofski NA, Stavroudis TA et al. Simulation: translation to improved team performance. Anesthesiol Clin 2007; 25: 301–319 23 Issenberg SB, McGaghie WC, Hart IR et al. Simulation technology for health care professional skills training and assessment. JAMA 1999; 282: 861–866 24 Issenberg SB, McGaghie WC, Petrusa ER et al. Features and uses of highfidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27: 10–28 25 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 November 30, 2013] 26 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 27 Kory PD, Eisen LA, Adachi M et al. Initial airway management skills of senior residents: simulation training compared with traditional training. Chest 2007; 132: 1927–1931 28 Lawn JE, Cousens S, Zupan J. Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900 29 Lee MO, Brown LL, Bender J et al. A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation. Acad Emerg Med 2012; 19: 577–585 30 Lynagh M, Burton R, Sanson-Fisher R. A systematic review of medical skills laboratory training: where to from here? Med Educ 2007; 41: 879–887 31 Maran NJ, Glavin RJ. Low- to high-fidelity simulation – a continuum of medical education? Med Educ 2003; 37: 22–28 32 Mayo PH, Hackney JE, Mueck JT et al. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med 2004; 32: 2422–2427 33 McGaghie WC, Draycott TJ, Dunn WF et al. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011; 6: S42–S47 34 McGaghie WC, Issenberg SB, Cohen ER et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med 2011; 86: 706–711

35 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 36 McGaghie WC, Siddall VJ, Mazmanian PE et al. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 2009; 135: 62 S–68 S 37 Mileder LP, Urlesberger B, Schwindt J et al. Compliance with guidelines recommending the use of simulation for neonatal and infant resuscitation training in Austria. Klin Padiatr 2014; 226: 24–28 38 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 39 Nadel FM, Lavelle JM, Fein JA et al. Teaching resuscitation to pediatric residents: the effects of an intervention. Arch Pediatr Adolesc Med 2000; 154: 1049–1054 40 O’Donnell CP, Kamlin CO, Davis PG et al. Interobserver variability of the 5-minute Apgar score. J Pediatr 2006; 149: 486–489 41 Patel D, Piotrowski ZH, Nelson MR et al. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001; 107: 648–655 42 Patel J, Posencheg M, Ades A. Proficiency and retention of neonatal resuscitation skills by pediatric residents. Pediatrics 2012; 130: 515–521 43 Perlman JM, Wyllie J, Kattwinkel J et al. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122: S516–S538 44 Roy KM, Miller MP, Schmidt K et al. Pediatric residents experience a significant decline in their response capabilities to simulated lifethreatening events as their training frequency in cardiopulmonary resuscitation decreases. Pediatr Crit Care Med 2011; 12: e141–e144 45 Scheuchenegger A, Lechner E, Wiesinger-Eidenberger G et al. Short-term morbidities of moderate and late preterm infants. Klin Padiatr 2013 [Epub ahead of print] 46 Schmölzer GM, Roehr CC. Use of respiratory function monitors during simulated neonatal resuscitation. Klin Padiatr 2011; 223: 261–266 47 Schroedl CJ, Corbridge TC, Cohen ER et al. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care 2012; 27: 219. e7–219.e13 48 Schwid HA, O’Donnell D. Anesthesiologists’ management of simulated critical incidents. Anesthesiology 1992; 76: 495–501 49 Segen JC. Concise dictionary of modern medicine. 1st ed. The McGrawHill Companies Inc., New York: 2006 50 Soar J, Monsieurs KG, Ballance JH et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation. Resuscitation 2010; 81: 1434–1444 51 Stichtenoth G, Demmert M, Bohnhorst B et al. Major contributors to hospital mortality in very-low-birth-weight infants: data of the birth year 2010 cohort of the German Neonatal Network. Klin Padiatr 2012; 224: 276–281 52 Thomas EJ, Taggart B, Crandell S et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. J Perinatol 2007; 27: 409–414 53 Thomas EJ, Williams AL, Reichman EF et al. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics 2010; 125: 539–546 54 Turner NM, Lukkassen I, Bakker N et al. The effect of the APLS-course on self-efficacy and its relationship to behavioural decisions in paediatric resuscitation. Resuscitation 2009; 80: 913–918 55 Wayne DB, Siddall VJ, Butter J et al. A longitudinal study of internal medicine residents’ retention of advanced cardiac life support skills. Acad Med 2006; 81: S9–S12 56 Weinberg ER, Auerbach MA, Shah NB. The use of simulation for pediatric training and assessment. Curr Opin Pediatr 2009; 21: 282–287 57 Weiner GM, Menghini K, Zaichkin J et al. Self-directed versus traditional classroom training for neonatal resuscitation. Pediatrics 2011; 127: 713–719 58 Weinstock PH, Kappus LJ, Kleinman ME et al. Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. Pediatr Crit Care Med 2005; 6: 635–641 59 Yee B, Naik VN, Joo HS et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology 2005; 103: 241–248

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

266 Review

Review 267 Appendix 1



EMBASE search strategy (last performed on 1 December 2013) Limits activated: “Randomized Controlled Trial” #1 “Infant” (Results: 9 778) #2 “Education” (Results: 3 419) #3 “Newborn” (Results: 5 472) #4 “Resuscitation” (Results: 980) #5 “Simulation” (Results: 640) #6 (#2) AND #4 (Results: 55) #7 (#4) AND #5 (Results: 36) #8 (#6) AND #5 (Results: 0) #9 (#8) AND #1 (Results: 0) #10 (#8) AND #3 (Results: 0)

Mileder LP et al. Simulation-Based Neonatal and Infant … Klin Padiatr 2014; 226: 259–267

Downloaded by: University of Pittsburgh. Copyrighted material.

PubMed search strategy (last performed on 1 December 2013) Limits activated: “Randomized Controlled Trial” #1 MeSH descriptor “Infant” explode all trees (Results: 19 005) #2 MeSH descriptor “Education” explode all trees (Results: 15 281) #3 MeSH descriptor “Infant, Newborn” explode all trees (Results: 9 134) #4 MeSH descriptor “Resuscitation” explode all trees (Results: 2 927) #5 “Simulation” (Results: 1 705) #6 (#2) AND #4 (Results: 260) #7 (#4) AND #5 (Results: 106) #8 (#6) AND #5 (Results: 75) #9 (#8) AND #1 (Results: 10) #10 (#8) AND #3 (Results: 7)

Simulation-based neonatal and infant resuscitation teaching: a systematic review of randomized controlled trials.

Current resuscitation guidelines recommend the use of simulation-based medical education (SBME) as an instructional methodology to improve patient saf...
278KB Sizes 2 Downloads 3 Views