Using screen-based simulation to improve performance during pediatric resuscitation

What can be learned from the literature about intervals and strategies for paediatric CPR retraining of healthcare professionals? A scoping review of literature

Background

Effective training and retraining may be key to good quality paediatric cardiopulmonary resuscitation (pCPR). PCPR skills decay within months after training, making the current retraining intervals ineffective. Establishing an effective retraining strategy is fundamental to improve quality of performance and potentially enhance patient outcomes.

Objective

To investigate the intervals and strategies of formal paediatric resuscitation retraining provided to healthcare professionals, and the associated outcomes including patient outcomes, quality of performance, retention of knowledge and skills and rescuer’s confidence.

Methods

This review was drafted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR). PubMed, Medline, Cochrane, Embase, CINAHL Complete, ERIC and Web of Science were searched and studies addressing the PICOST question were selected.

Results

The results indicate complex data due to significant heterogeneity among study findings in relation to study design, retraining strategies, outcome measures and length of intervention. Out of 4706 studies identified, 21 were included with most of them opting for monthly or more frequent retraining sessions. The length of intervention ranged from 2-minutes up to 3.5 hours, with most studies selecting shorter durations (<1h). All studies pointed to the importance of regular retraining sessions for acquisition and retention of pCPR skills.

Conclusions

Brief and frequent pCPR retraining may result in more successful skill retention and consequent higher-quality performance. There is no strong evidence regarding the ideal retraining schedule however, with as little as two minutes of refresher training every month, there is the potential to increase pCPR performance and retain the skills for longer.

Effects of Virtual Reality Simulation Program Regarding High-risk Neonatal Infection Control on Nursing Students

PURPOSE

Virtual reality simulation can give nursing students a safe clinical experience involving high-risk infants where access to neonatal intensive care units is limited. This study aimed to examine the effects of a virtual reality simulation program on Korean nursing students' knowledge, performance self-efficacy and learner satisfaction.

METHODS

A nonequivalent control group design was applied. Senior nursing students were divided into an experimental group (n = 25) experiencing virtual reality simulation and routine neonatal intensive care unit practice and a control group (n = 25) having routine neonatal intensive care unit practice. The program consisted of three scenarios: basic care, feeding management and skin care and environmental management for prevention of neonatal infection. The total execution time for the three scenarios was 40 minutes. The simulation created immersive virtual reality experiences using a head-mounted display with hand-tracking technology. Data were collected from December 9, 2019, to January 17, 2020, and were analyzed using descriptive statistics and the t-test, paired t-tests, Mann-Whitney test and Wilcoxon signed-ranks test.

RESULTS

Compared to the control group, the experimental group showed significantly greater improvements in high-risk neonatal infection control performance self-efficacy (t = -2.16, p = .018) and learner satisfaction (t = -5.59, p < .001).

CONCLUSION

The virtual reality simulation program can expand the nursing students' practice experience in safe virtual spaces and enhance their performance self-efficacy and learning satisfaction.

Health Care Providers' Performance, Mindset, and Attitudes Toward a Neonatal Resuscitation Computer-Based Simulator: Empirical Study

BACKGROUND

Neonatal resuscitation involves a complex sequence of actions to establish an infant's cardiorespiratory function at birth. Many of these responses, which identify the best action sequence in each situation, are taught as part of the recurrent Neonatal Resuscitation Program training, but they have a low incidence in practice, which leaves health care providers (HCPs) less prepared to respond appropriately and efficiently when they do occur. Computer-based simulators are increasingly used to complement traditional training in medical education, especially in the COVID-19 pandemic era of mass transition to digital education. However, it is not known how learners' attitudes toward computer-based learning and assessment environments influence their performance.

OBJECTIVE

This study explores the relation between HCPs' attitudes toward a computer-based simulator and their performance in the computer-based simulator, RETAIN (REsuscitation TrAINing), to uncover the predictors of performance in computer-based simulation environments for neonatal resuscitation.

METHODS

Participants were 50 neonatal HCPs (45 females, 4 males, 1 not reported; 16 respiratory therapists, 33 registered nurses and nurse practitioners, and 1 physician) affiliated with a large university hospital. Participants completed a demographic presurvey before playing the game and an attitudinal postsurvey after completing the RETAIN game. Participants' survey responses were collected to measure attitudes toward the computer-based simulator, among other factors. Knowledge on neonatal resuscitation was assessed in each round of the game through increasingly difficult neonatal resuscitation scenarios. This study investigated the moderating role of mindset on the association between the perceived benefits of understanding the terminology used in the computer-based simulator, RETAIN, and their performance on the neonatal resuscitation tasks covered by RETAIN.

RESULTS

The results revealed that mindset moderated the relation between participants' perceived terminology used in RETAIN and their actual performance in the game (F3,44=4.56, R2=0.24, adjusted R2=0.19; P=.007; estimate=-1.19, SE=0.38, t44=-3.12, 95% CI -1.96 to -0.42; P=.003). Specifically, participants who perceived the terminology useful also performed better but only when endorsing more of a growth mindset; they also performed worse when endorsing more of a fixed mindset. Most participants reported that they enjoyed playing the game. The more the HCPs agreed that the terminology in the tutorial and in the game was accessible, the better they performed in the game, but only when they reported endorsing a growth mindset exceeding the average mindset of all the participants (F3,44=6.31, R2=0.30, adjusted R2=0.25; P=.001; estimate=-1.21, SE=0.38, t44=-3.16, 95% CI -1.99 to -0.44; P=.003).

CONCLUSIONS

Mindset moderates the strength of the relationship between HCPs' perception of the role that the terminology employed in a game simulator has on their performance and their actual performance in a computer-based simulator designed for neonatal resuscitation training. Implications of this research include the design and development of interactive learning environments that can support HCPs in performing better on neonatal resuscitation tasks.

Midwifery students’ retention of learning after screen-based simulation training on neonatal resuscitation: a pilot study

Simulation in medical education is widely used to teach both technical and non-technical skills. The use of tools such as screen-based simulation raises the question of their efficiency and the retention rate for knowledge and skills. In this study, we measured midwives’ retention of learning after screen-based simulation training on neonatal resuscitation. 14 midwifery students participated in this pilot study. They undertook two screen-based simulation sessions 2 months apart. Measurements included a knowledge quiz, a self-efficacy assessment and two experts’ evaluations of the Anaesthetists’ Non-Technical Skills (ANTS) and Neonatal Resuscitation Performance Evaluation (NRPE) scoring (non-technical and technical skills, respectively). A demographic survey with open-ended questions on professional experience and learning concluded the study. We showed an improvement in the self-efficacy assessment (p<0.05), the knowledge quiz (p<0.01) and the ANTS evaluation (p<0.0001). However, there was no significant difference in the NRPE score. The students enjoyed the apprenticeship aspect of the screen-based simulation. Repeated exposure to a screen-based simulation on neonatal resuscitation could be advantageous for non-technical skills training, self-confidence and retention of knowledge. This is still a work in progress, undergoing further investigation with more participants and new variables.

Comparative Cost of Virtual Reality Training and Live Exercises for Training Hospital Workers for Evacuation

Adoption of virtual reality technology may be delayed due to high up-front costs with unknown returns on that investment. In this article, we present a cost analysis of using virtual reality as a training tool. Virtual reality was used to train neonatal intensive care workers in hospital evacuation. A live disaster exercise with mannequins was also conducted that approximated the virtual experience. Comparative costs are presented for the planning, development, and implementation of both interventions. Initially, virtual reality is more expensive, with a cost of $229.79 per participant (total cost $18 617.54 per exercise) for the live drill versus $327.78 (total cost $106 951.14) for virtual reality. When development costs are extrapolated to repeated training over 3 years, however, the virtual exercise becomes less expensive with a cost of $115.43 per participant, while the cost of live exercises remains fixed. The larger initial investment in virtual reality can be spread across a large number of trainees and a longer time period with little additional cost, while each live drill requires additional costs that scale with the number of participants.

Recent Advances in Technology and Its Applications to Pediatric Emergency Care

Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.

Improvement of Skills in Cardiopulmonary Resuscitation of Pediatric Residents by Recorded Video Feedbacks

OBJECTIVE

To evaluate the pediatric residents' cardiopulmonary resuscitation (CPR) skills, and their improvements after recorded video feedbacks.

METHODS

Pediatric residents from a university hospital were enrolled. The authors surveyed the level of pediatric resuscitation skill confidence by a questionnaire. Eight psychomotor skills were evaluated individually, including airway, bag-mask ventilation, pulse check, prompt starting and technique of chest compression, high quality CPR, tracheal intubation, intraosseous, and defibrillation. The mock code skills were also evaluated as a team using a high-fidelity mannequin simulator. All the participants attended a concise Pediatric Advanced Life Support (PALS) lecture, and received video-recorded feedback for one hour. They were re-evaluated 6 wk later in the same manner.

RESULTS

Thirty-eight residents were enrolled. All the participants had a moderate to high level of confidence in their CPR skills. Over 50 % of participants had passed psychomotor skills, except the bag-mask ventilation and intraosseous skills. There was poor correlation between their confidence and passing the psychomotor skills test. After course feedback, the percentage of high quality CPR skill in the second course test was significantly improved (46 % to 92 %, p = 0.008).

CONCLUSIONS

The pediatric resuscitation course should still remain in the pediatric resident curriculum and should be re-evaluated frequently. Video-recorded feedback on the pitfalls during individual CPR skills and mock code case scenarios could improve short-term psychomotor CPR skills and lead to higher quality CPR performance.

Development and Testing of Screen-Based and Psychometric Instruments for Assessing Resident Performance in an Operating Room Simulator

Introduction. Medical simulators are used for assessing clinical skills and increasingly for testing hypotheses. We developed and tested an approach for assessing performance in anesthesia residents using screen-based simulation that ensures expert raters remain blinded to subject identity and experimental condition. Methods. Twenty anesthesia residents managed emergencies in an operating room simulator by logging actions through a custom graphical user interface. Two expert raters rated performance based on these entries using custom Global Rating Scale (GRS) and Crisis Management Checklist (CMC) instruments. Interrater reliability was measured by calculating intraclass correlation coefficients (ICC), and internal consistency of the instruments was assessed with Cronbach's alpha. Agreement between GRS and CMC was measured using Spearman rank correlation (SRC). Results. Interrater agreement (GRS: ICC = 0.825, CMC: ICC = 0.878) and internal consistency (GRS: alpha = 0.838, CMC: alpha = 0.886) were good for both instruments. Subscale analysis indicated that several instrument items can be discarded. GRS and CMC scores were highly correlated (SRC = 0.948). Conclusions. In this pilot study, we demonstrated that screen-based simulation can allow blinded assessment of performance. GRS and CMC instruments demonstrated good rater agreement and internal consistency. We plan to further test construct validity of our instruments by measuring performance in our simulator as a function of training level.

Simulation-based medical education in pediatrics

The use of simulation-based medical education (SBME) in pediatrics has grown rapidly over the past 2 decades and is expected to continue to grow. Similar to other instructional formats used in medical education, SBME is an instructional methodology that facilitates learning. Successful use of SBME in pediatrics requires attention to basic educational principles, including the incorporation of clear learning objectives. To facilitate learning during simulation the psychological safety of the participants must be ensured, and when done correctly, SBME is a powerful tool to enhance patient safety in pediatrics. Here we provide an overview of SBME in pediatrics and review key topics in the field. We first review the tools of the trade and examine various types of simulators used in pediatric SBME, including human patient simulators, task trainers, standardized patients, and virtual reality simulation. Then we explore several uses of simulation that have been shown to lead to effective learning, including curriculum integration, feedback and debriefing, deliberate practice, mastery learning, and range of difficulty and clinical variation. Examples of how these practices have been successfully used in pediatrics are provided. Finally, we discuss the future of pediatric SBME. As a community, pediatric simulation educators and researchers have been a leading force in the advancement of simulation in medicine. As the use of SBME in pediatrics expands, we hope this perspective will serve as a guide for those interested in improving the state of pediatric SBME.

Toward a new paradigm: goal-based residency training

OBJECTIVES

Many factors affect the clinical training experience of emergency medicine (EM) residents, and length of training currently serves as a proxy for clinical experience. Very few studies have been published that provide quantitative information about clinical experience. The goals of this study were to determine the numbers of clinical encounters for each resident in emergency department (ED) rotations during training in a 3-year program, to characterize these encounters by patient acuity and age, to determine the numbers of encounters for selected clinical disorders, and to assess the variation in clinical experience between residents.

METHODS

This was a retrospective analysis of the ED clinical and administrative databases at two hospitals that provide EM training for a southeastern U.S. EM residency program. Data were gathered for three complete cohorts of residents, with entering years of 2003, 2004, and 2005, so the total study period was 2003-2008. ED clinical encounter information included hospital training site (tertiary or community), postgraduate year (PGY) of the resident, patient triage acuity reflected by the Emergency Severity Index (ESI); patient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code; and patient age group.

RESULTS

There were 25 residents with 120,240 total ED clinical encounters from 2003 to 2008. The median number of ED clinical encounters for a resident during his or her training was 4,836 (range = 3,831 to 5,780), based on a maximum of an 80-hour work week, and 24 or 25 four-week blocks of EM rotations. Overall, clinical encounters increased by 30% from PGY 1 to PGY 2, and another 14% from PGY 2 to PGY 3. There was 30% to 60% variation in clinical encounters between individual residents. Variability was most prominent in the care of children and in the care of time-sensitive critical illness. Resident encounters with lower-acuity problems during training were much less than the anticipated lower-acuity burden during practice. Additionally, residents did not encounter some high-risk conditions clinically during the study period.

CONCLUSIONS

Methods should be developed to decrease resident variance in both numbers and types of clinical encounters and to provide curriculum supplementation for individuals and for the entire residency cohort in areas that are important for the clinical practice of EM, but that are rare or not encountered during residency training.

The European Paediatric Life Support course improves assessment and care of dehydrated children in the emergency department

We tested the hypothesis that application of the principles learned from the European Paediatric Life Support (EPLS) course improves child health assessment and care. In a retrospective study, residents from five paediatric emergency departments were included. For each of them, we analysed five medical records of infants and children suffering from diarrhoea; three were in ambulatory care and two were in-hospital care with IV hydration. Two independent observers analysed the records using a standardized checklist of 14 clinical points, as well as three items to evaluate the adequacy of treatment according to hydration status. Agreement between readers was evaluated the kappa coefficient of concordance. Statistical associations between each item and the EPLS course status was assessed by logistic regression taking into account the clustered data structure. Fifty residents and 240 medical records were included. Twenty-six residents were EPLS trained (intervention group) and 24 residents were not (control group). The results of the analyses of the medical records by the observers were concordant (kappa >0.91). Medical records in the intervention group contained more clinical information on circulatory status (P < 0.0001). Residents in the intervention group prescribed goal-directed therapy more often (P = 0.006). For children with shock, they administered volume resuscitation (P = 0.01) with goal-directed therapy more often (P = 0.003). This is the first evaluation of an educational program focusing on the actions of "learners" in the clinical environment. Our findings highlight that the EPLS course is associated with a better clinical analysis of hydration and circulation status as well as with goal-directed therapy.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.

Critical appraisal of emergency medicine educational research: the best publications of 2009

OBJECTIVES

The objective was to critically appraise and highlight methodologically superior medical education research specific to emergency medicine (EM) published in 2009.

METHODS

A search of the English language literature in 2009 querying Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE 1950 to Present, Web of Science, Education Resources Information Center (ERIC), and PsychInfo identified 36 EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This was a refinement of the methods used to appraise medical education published in 2008.

RESULTS

Seven studies met the standards as determined by the averaged rankings and are highlighted and summarized here. This year, 16 of 36 (44%) identified studies had funding, compared to 11 of 30 (36%) identified last year; five of seven (71%) highlighted publications were funded in 2009 compared to three of five (60%) highlighted in 2008. Use of technology in medical education was reported in 14 identified and four highlighted publications, with simulation being the most common technology studied. Five of the seven (71%) featured publications used a quasi-experimental or experimental design, one was observational, and one was qualitative. Practice management topics, including patient safety, efficiency, and revenue generation, were examined in seven reviewed studies.

CONCLUSIONS

Thirty-six medical education publications published in 2009 focusing on EM were identified. This critical appraisal reviews and highlights seven studies that met a priori quality indicators. Current trends are noted.