Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety

Just-in-Time Video Using QR Codes: An Approach to Pediatric Trauma Nursing Education

BACKGROUND

High acuity trauma and patients in cardiopulmonary arrest are not frequently seen in all pediatric Level I trauma centers. Yet, nurses are required to manage these patients in fast-paced, high-pressure environments.

OBJECTIVE

This project aims to develop and evaluate an education program for high-risk, low-volume equipment and skills in the pediatric emergency department setting.

METHODS

This is a pre- and post-quality improvement study conducted in a Northeastern United States pediatric Level I trauma center. Emergency department nurses were invited to view videos detailing high-risk, low-volume equipment use. For the convenience of access, Quick Response (QR) codes linked to the videos were placed on each piece of equipment reviewed. General self-efficacy and levels of self-efficacy in using the equipment were assessed before the intervention and again after 4 weeks from January to February 2023.

RESULTS

A total of 43 pediatric emergency nurses participated in the education. The mean aggregate general self-efficacy score was 32.93. Mean scores in all areas (Level 1 rapid infuser, fluid warmer, blood administration, and securing an endotracheal tube) improved after the intervention.

CONCLUSIONS

Easily accessible, brief refresher videos linked to QR codes in the pediatric emergency department can help empower nurses who need to use high-risk, low-volume equipment.

Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial

OBJECTIVE

To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI).

STUDY DESIGN

A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests.

RESULTS

Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P = .71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P = .035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P = .048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P = .02). There were more mucosal trauma events in the simulation-based JITT group (P = .02). Residents in both groups reported similar confidence level in performing ETI.

CONCLUSIONS

Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02809924.

The Impact of a 3-Tiered Model of Nursing Redeployment During the COVID-19 Pandemic: A Cross-Sectional Study

Objective

The COVID-19 pandemic resulted in extreme system pressures, requiring redeployment of nurses to intensive care units (ICUs). We aimed to assess the impacts of a 3-tiered pandemic surge model on nurses working in ICUs during the COVID-19 pandemic.

Methodology

In this cross-sectional study, 931 nurses (464 ICU and 467 redeployed nurses) who worked within 4 adult ICUs in Western Canada during pandemic surge(s) were invited via email to participate in a survey. The survey explored the impact of redeployment, rapid ICU orientations, just-in-time training, and the 3-tiered model of nursing during pandemic surge. Burnout was measured utilizing the Copenhagen Burnout Inventory questionnaire.

Results

A total of 191 survey responses were retained (59 ICU nurses and 132 redeployed). Survey results are reported by tier, with outcomes varying based on team leadership, ICU, and redeployment nursing roles. Burnout in personal and workplace domains was present amongst all nursing tiers, while only team leadership roles experienced burnout in the patient domain. Overall, team leadership roles and permanent ICU nurses experienced the highest rates of burnout. Redeployed nurses reported numerous aids to success including support from colleagues, prior experience, and educational supports. Skill-based orientation, ongoing education, optimized scheduling, role clarity, and mitigators of psychological impacts were identified by respondents as potential facilitators of redeployment and surge models.

Conclusion

Nurses working within this tiered model experienced high degrees of burnout, with highest prevalence amongst team leads and ICU nurses. Optimization of support for and interventions aimed at improving well-being are important considerations going forward.

Intervention Development: Quick Response Code Implementation for Point-of-Care Training Needs in the Emergency Department

The rise of a digital native generation of nurses entering the ED workforce prompts a need for targeted training resources to meet their needs and preferences. The purpose of this intervention was to (1) leverage Quick Response code technology to provide point-of-care information as it relates to high-risk, low-volume therapies, (2) improve staff nurse perception toward the ease of access to educational and training materials, and (3) improve staff perception of the adequacy of educational and training resources. Training videos ranging in length from 2 to 3 minutes were created and linked through Quick Response codes for smartphone scanning and affixed to relevant pieces of equipment. Nurses were asked to complete project-specific surveys before implementation (n = 20) and at 4 months postimplementation (n = 26). After the second project-specific survey, nearly all (96.2%) of the surveyed nurses described their ease of access to informational materials as extremely easy or somewhat easy. Approximately 93.7% stated yes to having adequate educational resources to meet their training needs, an increase of 50% in comparison with the first project-specific survey. There is a great opportunity to capitalize on the potential preferences of this younger, technologically savvy generation of nurses through Quick Response code implementation and point-of-care training to improve competency with high-risk, low-volume therapies. This intervention could also be tailored to many other aspects of nurse training and education in various settings.

Quick Response Codes: An Innovative Approach to Just-in-Time Education

BACKGROUND

Many nurses are digital natives who have grown up with advanced technology. Bedside competence is essential, and written policies and procedures guide our practice. Newer learning styles, time constraints, and available personnel may be barriers to historical approaches to information dissemination.

METHODS

Quick Response code technology was incorporated to provide just-in-time resources that can be readily accessed at the point of care.

RESULTS

Nurses have incorporated Quick Response codes in novel ways to provide quick resources in a dynamic environment. Examples include orientation documents, educational rollouts, infrequently used and high-risk equipment, and leadership updates.

IMPLICATIONS

Bedside nurses in our institution have embraced this technology. Benefits include engagement, increased knowledge, and a sense of value among our nursing team.

Analysis of Student Perceptions of Just-In-Time Teaching Pedagogy in PharmD Microbiology and Immunology Courses

Just-In-Time Teaching (JiTT) active learning pedagogy is utilized by various disciplines, but its value in a professional pharmacy curriculum has not yet been demonstrated. The purpose of our research study is to implement and evaluate JiTT in a Doctor of Pharmacy (PharmD) program. The impetus in implementing JiTT into a PharmD curriculum was to provide students with an out-of-classroom learning opportunity to enhance knowledge-based skills. The current study summarizes the implementation of JiTT in four distinct instances: two iterations of the required courses "Integrated Microbiology and Virology" (Fall 2016 and Fall 2017) and "Integrated Immunology" (Winter 2016-2017 and Winter 2017-2018). JiTT included knowledge-based questions in multiple-choice format, integrated case studies, and student responses prior to the actual lecture session. After the conclusion of each course, students were asked to provide feedback on the utilization of JiTT by way of an anonymous survey. Following the Fall 2016 iteration of the Microbiology & Virology course, students found the integrated case studies to be beneficial (mean = 3.27 out of a maximum of 4, SD = 0.62), and their overall endorsement of JiTT was high (mean = 3.61 out of 4, SD = 0.50). For the other three courses included in this study, the primary dependent variable was the student's average rating of JiTT, rated on a five-point scale. Aggregating the scores from the Fall 2017 iteration of the Integrated Microbiology & Virology course and both instances of the Immunology course, students rated JiTT very favorably (mean = 4.17 out of a maximum of 5, SD = 0.77). Students' performances in JiTT-based courses were compared against non-JiTT-based courses. Analysis of assessment data for student's performance on knowledge-based questions showed JiTT was helpful for student learning and JiTT-based courses had more consistent exam scores compared to non-JiTT-based courses. The current results are a promising initial step in validating the usefulness of JiTT in a pharmacy program and lays the foundation for future studies aimed at a direct comparison between a traditional lecture style and JiTT pedagogy implemented into PharmD curricula.

Nurses' just-in-time training for clinical deterioration: Development, implementation and evaluation

BACKGROUND

'Just-in-time training' is an innovative approach to nursing education. It has demonstrated positive outcomes in other industries, such as manufacturing and aviation, but it has limited published application in the acute-care setting.

OBJECTIVES

We aimed to implement and evaluate a nursing 'just-in-time training' program for the recognition and response to patient deterioration.

DESIGN

To promote consistency, one Clinical Deterioration Educator provided education to nursing staff in both recognising the need for escalation and providing subsequent care for the deteriorating ward patient. Nurses' perception of the 'just-in-time training' program was determined using electronic questionnaire responses. Medical Emergency Team call prevalence and outcome data was compared before and after the program implementation for further evaluation.

SETTING

The 'just-in-time training' program was implemented in a 508-bed acute metropolitan private hospital over a 12-month period. Education was provided in general medical and surgical wards, not specialty areas.

PARTICIPANTS

Nurses received the just-in-time training based on their patients' perceived risk of deterioration, therefore, participants are not randomised.

METHODS

A quantitative research study investigated nurses' self-perceived confidence after receiving just-in-time training. Medical Emergency Team call frequency data was also examined to identify trends.

RESULTS

The 'just-in-time training' program consisted of 534 bedside nursing encounters over 12 months. During the study, the need for the educator to recommend that nurses escalate care reduced in prevalence from 20% to 5.5%. Questionnaire responses demonstrated a self-perceived confidence following intervention of 4.32/5.0. Medical Emergency Team call prevalence, per 1000 patient bed days, increased from 13.6 pre-intervention to 15.4 post-intervention.

CONCLUSIONS

Just-in-time training' can be effectively implemented to educate ward nursing staff in recognising and responding to the deteriorating patient. The program is well received by nursing staff and leads to high self-perceived confidence to recognise and appropriately care for a deteriorating patient.

Pulmonary Artery Catheters: Impact of e-Learning on Hemodynamic Assessments

Pulmonary artery catheters (PACs) are invasive devices placed in critically ill patients to monitor hemodynamic data. They are a high-risk, and in some settings a low-volume, medical device due to the complex insertion procedure and potentially lethal complications. Smaller intensive care units (ICUs) have large variances in exposure to PACs, therefore strengthening ICU nurses' belief in their ability to manage these hemodynamic monitoring devices is of utmost importance. The design is a single-group, pre/posttest study conducted on a 15-bed ICU to survey nurses' self-efficacy, knowledge, and satisfaction of an e-learning educational module. Both PAC and noninvasive cardiac output monitor patient application data were collected prior to and following the intervention. Fifteen ICU nurses completed all components of the module. Confidence in ability to accurately interpret hemodynamic data increased from pre- to postintervention (P < .001), and knowledge also increased from pre- to postintervention, albeit not statistically significantly (P = .088). Overall, nurses reported satisfaction with the educational module. With increased self-efficacy, nurses can feel empowered and motivated to further improve patient care management. Thus, workplaces should continue to advocate for additional educational tools for high-risk, low-volume devices.

Just-in-Time Training for Intraosseous Needle Placement and Defibrillator Use in a Pediatric Emergency Department

OBJECTIVES

Just-in-time training (JITT) is a method of simulation-based training where the training occurs within the clinical environment in a concise manner. Just-in-time training has shown effects at the learner, patient, and system-wide levels. We evaluated a JITT curriculum for the procedures of intraosseous (IO) needle placement and defibrillator use in a pediatric emergency department (ED) by comparing the trainees' comfort level in performing those procedures independently (Kirkpatrick level 2a) and trainees' knowledge of the procedures/equipment (Kirkpatrick level 2b) before and after the JITT.

METHODS

The study enrolled all fourth year medical students and residents (family medicine and pediatrics) who rotated through a children's hospital ED. The JITT curriculum included group discussion on storage locations of procedure equipment in the ED and clinical indications/contraindications followed by hands-on procedure training. One of 2 attending physicians facilitated the 10- to 20-minute JITT in the ED during their shifts. Trainees completed an anonymous survey to delineate medical training level, previous procedure experiences, procedure-related knowledge, and comfort level to perform the procedures independently. Identical surveys were completed before and after the JITT. The data were analyzed using percentage for categorical variables. For comparisons between pre-JITT and post-JITT survey data, χ tests or Fisher exact tests were used.

RESULTS

There were 65 surveys included (34 pre-JITT and 31 post-JITT surveys). The comfort level to perform procedures independently increased from pre-JITT 0% to post-JITT 48% (P < 0.001) for IO needle placement and from pre-JITT 3% to post-JITT 32% (P = 0.0016) for defibrillator use. The procedure-related knowledge also increased by ##greater than or equal to 50% post-JITT (P < 0.0001).

CONCLUSIONS

Our JITT curriculum significantly increased the comfort level of the trainees to perform IO needle insertion and defibrillator use independently. Procedure-related knowledge also increased. By increasing their comfort to perform these procedures independently, we aim to increase the likelihood that trainees can be competent contributing members of an acute medical response team in these respective roles.

Improving the Performance of Anthropometry Measurements in the Pediatric Intensive Care Unit

Supplemental Digital Content is available in the text.

Introduction:

Obtaining anthropometry measurements in critically ill children is challenging. Our objective was to improve the process of obtaining anthropometry measurements in the pediatric intensive care unit (PICU; even if previously obtained) using a dedicated PICU nutrition support team (NST).

Methods:

PICU staff were trained to perform anthropometry measurements through online education, skills training, and just-in-time bedside teaching by the PICU NST. Equipment was upgraded and standardized throughout the PICU along with implementation of preselected orders in the electronic medical record. Data were collected before and immediately after intervention and at monthly intervals from 12 to 36 months to test sustainability of practice change. PICU staff were surveyed on barriers to anthropometry measurements at 36 months after initial intervention.

Results:

Compared with baseline, the intervention resulted in more patients with orders for weight, stature, and head circumference (all P < 0.001) at PICU admission. Correspondingly, more patients had measurements of weight (P = 0.04), stature (P = 0.01), and head circumference (P = 0.009) at PICU admission. For long-stay patients (>7 days), compliance improved with measurements of serial weights (P = 0.002), stature (P < 0.001), and head circumference (P = 0.02). Between 12 and 36 months after the intervention, there was a noticeable trend to increases in weight measurements at PICU admission, and to a lesser extent, of stature and head circumference. Competing clinical priorities were a key barrier to anthropometry measurements.

Conclusions:

Performance of anthropometry measurements in the PICU can be improved by a dedicated PICU NST; however, sustaining these improvements is challenging due to competing clinical priorities.

Gastroschisis Simulation Model: Pre-surgical Management Technical Report

This technical report describes the creation of a gastroschisis model for a newborn. This is a simple, low-cost task trainer that provides the opportunity for Neonatology providers, including fellows, residents, nurse practitioners, physician assistants, and nurses, to practice the management of a baby with gastroschisis after birth and prior to surgery. Included is a suggested checklist with which the model can be employed. The details can be modified to suit different learning objectives.

Quantifying Supply of Home Health Services for Public Health Emergencies

The number of persons seeking medical treatment during a public health emergency could quickly overwhelm the capacity of hospitals and emergency rooms. The amount of surge capacity home health care could provide during a public health emergency is unknown. The purpose of this research is to quantify the surge capacity of the home health sector in four emergency scenarios. According to the model developed, routine demand will exceed scenario capacity for almost all home health agencies in all pessimistic cases for the four scenarios discussed. However, home health agencies have the surge capacity to contribute to the provision of care for patients during times of demand under routine operating conditions as well as in conditions where demand may be moderately increased.