Effectiveness of a High-Fidelity Simulation-Based Training Program in Managing Cardiac Arrhythmias in Children: A Randomized Pilot Study

Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates

Background

More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.

Methods

This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.

Results

A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001).

Conclusions/discussion

This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

A manikin or human simulator-development of a tool for measuring students' perception

Background

Education with the use of medical simulation may involve the use of two modalities: manikins or standardized patients (SPs) to meet specific learning objectives. We have collected students' opinions about the two modalities which can be helpful in planning and evaluating the curriculum process. Although reviews or comparisons of student opinions appear in the literature, it is difficult to find a scale that would be based on a comparison of specific effects that can be obtained in the educational process. In order to fill this gap, an attempt was made to construct a questionnaire.

Methods

An experimental version of a questionnaire measuring the final-year students' (273) opinions about the effectiveness of both simulation techniques has been designed on the basis of semi-structured interviews. They were conducted with 14 final-year students excluded from the subsequently analyzed cohort. The scale has been completed, tested and validated.

Results

The authors developed a 33-statement questionnaire which contain two scales: teaching medicine with the manikins and with the SPs. Two factors were identified for each scale: Doctor-patient relationship and practical aspects. The scales can be used complementary or separately, as the article reports independent statistics for each scale. The Cronbach's alpha coefficient for the manikin scale is 0.721 and for the SP scale is 0.758.

Conclusions

The questionnaire may be applied to medical students to identify their opinions about using manikins and SPs in teaching. It may have an important impact for planning curriculum and implementing particular modalities in accordance with the intended learning objectives.

Investigating the Effectiveness of Using a Situated Simulation-Based Program to Improve Occupational Therapy Students' Interactions and Observation Skills with Children

Purpose

Interaction and observation are critical skills for occupational therapists who work with pediatric clients. The objective of this study was to investigate whether using standardized child patients within a situated simulation-based (SSB) program increases students' knowledge and clinical skills when working with children in occupational therapy.

Materials and Methods

This controlled trial with multiple measures recruited students from the pediatric occupational therapy curriculum enrolled in an SSB program in consecutive academic years (n = 62). Experimental group students participated in a simulation experience with video training sessions, followed by an SSB exam with standardized child patients; the control group performed the video training simultaneously. Quantitative outcomes included quizzes to measure clinical knowledge, video training scores, and a situated simulation exam to assess clinical skills.

Results

The experimental group had a significantly higher postwritten quiz scores than the control group; the video training scores were not significantly different between groups. Linear regression analysis showed a significant association between the SSB exam and postwritten quiz scores (β = 0.487, p = 0.017). The experimental group had a total pass rate of 65.6% for the SSB exam. The communication and interaction pass rate was 53.1%; the basic evaluation rate was 68.8%, implying that communication/interaction skills are hard to simulate from video training alone; therefore, the authentic fidelity of the SSB program needs to improve further to enhance learning.

Conclusions

The SSB program with standardized child patients improved students' clinical knowledge and skills more than lectures and practice alone. Using standardized child patients in programs or exams appears to positively influence students' performance. Situated simulation-based learning that allows the realistic practice of observation and communication skills may enhance students' clinical competency. Future research should develop standard training methods and evaluation processes in high-fidelity simulations for generalized use in other occupational therapy programs.

Manikins versus simulated patients in emergency medicine training: a comparative analysis

PURPOSE

Every physician must be able to sufficiently master medical emergencies, especially in medical areas where emergencies occur frequently such as in the emergency room or emergency surgery. This contrasts with the observation that medical students and young residents often feel insufficiently prepared to handle medical emergencies. It is therefore necessary to train them in the treatment of emergency patients. The aim of this study is to analyze the influence of the assignment of manikin versus simulated patients during a training for undergraduate medical students on learning outcomes and the perceived realism.

METHODS

The study had a prospective cross-over design and took place in a 3-day emergency medicine training for undergraduate medical students. Students completed three teaching units ('chest pain', 'impaired consciousness', 'dyspnea'), either with manikin or simulated patient. Using a questionnaire after each unit, overall impression, didactics, content, the quality of practical exercises, and the learning success were evaluated. The gained competences were measured in a 6-station objective structured clinical examination (OSCE) at the end of training.

RESULTS

126 students participated. Students rated simulated patients as significantly more realistic than manikins regarding the possibility to carry out examination techniques and taking medical history. 54.92% of the students would prefer to train with simulated patients in the future. Regarding the gained competences for 'chest pain' and 'impaired consciousness', students who trained with a manikin scored less in the OSCE station than the simulated patients-group.

CONCLUSION

Simulated patients are rated more realistic than manikins and seem to be superior to manikins regarding gained competence.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND

The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training.

METHODS

This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument.

RESULTS

A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%).

CONCLUSIONS

This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

Does Use of High-fidelity Simulation Improve Resident Physician Competency and Comfort Identifying and Managing Bradyarrhythmias?

Introduction: A workshop was designed to evaluate whether high-fidelity simulation with interactive case discussion could improve resident physician knowledge and comfort interpreting and managing bradyarrhythmias. 

Methods: All the residents completed a pre-test and then participated in a one-hour interactive presentation, which included practice interpreting rhythm strips and 12-lead electrocardiograms. Forty-four residents were assigned to the intervention group and completed 10 simulated cases using a mannequin, a real defibrillator/external pacemaker, a medication cart, and a simulated telemetry monitor displaying real-time electrocardiograms under the guidance of two instructors. Seventeen residents were assigned to the control group and completed the same 10 cases using interactive discussion with the same instructors but without the use of the high-fidelity simulation models. All residents underwent post-testing. 

Results: For the intervention group, the mean pre- and post-test knowledge scores were 13.93 and 17.28 (p=0.0001), and the mean pre- and post-test comfort scores were 2.92 and 4.24 (p=0.0001). For the control group, the mean pre- and post-test knowledge scores were 14.52 and 18.00 (p=0.005), and the mean pre- and post-test comfort scores were 2.97 and 4.35 (p=0.001). There were no statistically significant differences between pre-test and post-test knowledge and comfort scores for the two groups (p=0.633, p=0.421, p=0.177).

Conclusion: Interactive workshops help improve resident knowledge and comfort with identifying and managing bradycardias. The use of high-fidelity simulation models may not be superior to a similar interactive learning experience without the use of high-fidelity simulation tools. 

Nursery Assistants' Performance and Knowledge on Cardiopulmonary Resuscitation: Impact of Simulation-Based Training

Background: Child cardiac arrest is rare, but more frequent among infants, requiring immediate cardiopulmonary resuscitation (CPR). Many studies have reported that simulation-based training (SBT) increased CPR performance of healthcare providers. However, the CPR performance of laypeople using basic life support remains poorly known. The aim of this study was to assess nursery assistants' (non-healthcare providers) CPR performance and knowledge, before and after SBT. Methods: The study was carried out from January to June 2018 in the city of Poitiers, France. Two teaching sessions (T1 and T2) and two evaluation sessions (E1 and E2) were performed. Performance in infant CPR on a manikin at E1 and E2 were videotaped and assessed automatically with Resusci Baby QCPR® and a SimPad PLUS SkillReporter (QCPR Global Score and skills) and by an observer using an original CPR performance checklist (MCPR Global-Score and skills). Nursery assistant's CPR knowledge was assessed by a questionnaire at the beginning and the end of the session T1, E1, and E2. Results: Twenty-Seven nursery assistants over 30 contacted were included. There was an improvement between E1 and E2 in QCPR Global-Score (E1: 42.4 ± 23.6 vs. E2: 55.1 ± 23.7%, p = 0.032), MCPR Global-Score (E1: 50.0+11.9 vs. E2: 72.3+8.5%; p < 0.001) and theoretical knowledge with score (over 45) of 16.9+5.4 before T1 and 35.2+2.7 after E2, respectively (p < 0.001). The improvement mainly concerned QCPR and MCPR compression steps scores. MCPR Global-Score was strongly correlated to QCPR Global-Score (r = 0.61; p < 0.01) and predictive to CPR quality determined by QCPR Global-Score (AUC = 0.77; p < 0.01) with a high sensitivity and negative predictive values. Moreover, these improvements were maintained 2 months after training with no difference between scores obtained by the three groups 15, 30, or 60 days after simulation-based training session T2. Conclusion: SBT could significantly improve knowledge and skills in infant CPR management by nursery assistants especially for chest compression. CPR performance checklist appeared as an interesting tool to assess CPR performance quality.

Effects of Blindfold on Leadership in Pediatric Resuscitation Simulation: A Randomized Trial

Background: Pediatric resuscitations are rare events. Simulation-based training improves clinical and non-clinical skills, as well as survival rate. We assessed the effectiveness of using blindfolds to further improve leadership skills in pediatric simulation-based training. Methods: Twelve teams, each composed of 1 pediatric emergency fellow, 1 pediatric resident, and 2 pediatric emergency nurses, were randomly assigned to the blindfold group (BG) or to the control group (CG). All groups participated in one session of five simulation-based resuscitation scenarios. The intervention was using a blindfold for the BG leader for the scenarios B, C, and D. Three evaluators, who were blinded to the allocation, assessed leadership skills on the first and last video-recorded scenarios (A and E). Questionnaires assessed self-reported changes in stress and satisfaction about skills after the first and the last scenarios. Results: Improvement in leadership skills doubled in the BG compared with the CG (11.4 vs. 5.4%, p = 0.04), whereas there was no increase in stress or decrease in satisfaction. Conclusion: Blindfold could be an efficient method for leadership training during pediatric resuscitation simulated scenarios. Future studies should further assess its effect at a follow-up and on clinical outcomes after pediatric resuscitation.

Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2016

OBJECTIVES

The objectives were to critically appraise the emergency medicine (EM) medical education literature published in 2016 and review the highest-quality quantitative and qualitative studies.

METHODS

A search of the English language literature in 2016 querying MEDLINE, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified 510 papers related to medical education in EM. Two reviewers independently screened all of the publications using previously established exclusion criteria. The 25 top-scoring quantitative studies based on methodology and all six qualitative studies were scored by all reviewers using selected scoring criteria that have been adapted from previous installments. The top-scoring articles were highlighted and trends in medical education research were described.

RESULTS

Seventy-five manuscripts met inclusion criteria and were scored. Eleven quantitative and one qualitative papers were the highest scoring and are summarized in this article.

CONCLUSION

This annual critical appraisal series highlights the best EM education research articles published in 2016.

Video Monitoring a Simulation-Based Quality Improvement Program in Bihar, India

BACKGROUND

Simulation-based training has become an accepted clinical training andragogy in high-resource settings with its use increasing in low-resource settings. Video recordings of simulated scenarios are commonly used by facilitators. Beyond using the videos during debrief sessions, researchers can also analyze the simulation videos to quantify technical and nontechnical skills during simulated scenarios over time. Little is known about the feasibility and use of large-scale systems to video record and analyze simulation and debriefing data for monitoring and evaluation in low-resource settings.

METHODS

This manuscript describes the process of designing and implementing a large-scale video monitoring system. Mentees and Mentors were consented and all simulations and debriefs conducted at 320 Primary Health Centers (PHCs) were video recorded. The system design, number of video recordings, and inter-rater reliability of the coded videos were assessed.

RESULTS

The final dataset included a total of 11,278 videos. Overall, a total of 2,124 simulation videos were coded and 183 (12%) were blindly double-coded. For the double-coded sample, the average inter-rater reliability (IRR) scores were 80% for nontechnical skills, and 94% for clinical technical skills. Among 4,450 long debrief videos received, 216 were selected for coding and all were double-coded. Data quality of simulation videos was found to be very good in terms of recorded instances of "unable to see" and "unable to hear" in Phases 1 and 2.

CONCLUSION

This study demonstrates that video monitoring systems can be effectively implemented at scale in resource limited settings. Further, video monitoring systems can play several vital roles within program implementation, including monitoring and evaluation, provision of actionable feedback to program implementers, and assurance of program fidelity.