Review of Simulation in Pediatrics: The Evolution of a Revolution

Role of simulation-based training and assessment to improve brachytherapy competency among radiation oncology residents

Simulation is a technique used in healthcare to replicate clinical scenarios and improve patient safety, efficacy, and efficiency. Simulation-based medical education facilitates training and assessment in healthcare without increasing risk to patients, supported by ample evidence from surgical/procedural specialties. Simulation in radiation oncology has been leveraged to an extent, with successful examples of both screen-based and hands-on simulators that have improved confidence and performance in trainees. In the current era, evidence substantiates a significant deficit in brachytherapy procedure education, with radiation oncology residents reporting low confidence in this procedural skill, largely attributable to insufficient caseloads at some centers. Simulation-based medical education can facilitate structured training and competency-based assessment in brachytherapy skills. This review discusses existing advances and future directions in brachytherapy simulation, using examples from simulation in surgical specialties.

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study

OBJECTIVE

To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students.

METHODS

33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge's g.

RESULTS

Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20).

CONCLUSION

HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

What is the impact of simulation-based training for paediatric procedures on patient outcomes, cost and latent safety threats?

BACKGROUND

Simulation-based training (SBT) provides a safe space for medical trainees to experience realistic scenarios. SBT has been found to improve trainee performance in paediatric procedures. However, limited evidence exists regarding its effects on higher-level outcomes. This scoping review aims to identify studies that investigate the impact of SBT for procedural skills on T3 (patient outcomes) and T4 level outcomes (latent safety threats [LSTs], and hospital level costs) in paediatrics.

METHODS

Full-text articles were included if they focused on medical trainees, used simulation training for paediatric procedures and reported T3/T4 level outcomes. Six databases were searched from January 2011 to September 2022. Search strategies were developed with the assistance of a librarian. Three independent reviewers performed pilot screenings before title/abstract and full-text screenings. A data extraction sheet was created to gather information on interventions, outcomes, research design, and other study characteristics.

FINDINGS

After title/abstract screening of 4,076 sources, 50 were included for full-text review, with 15 articles selected for data extraction. Four were randomised control studies (RCTs), fourteen focused on T3 level outcomes including mortality rates, and one measured LSTs. There were no studies reporting cost-related data. Three of the studies focused on bag-and-mask ventilation, and eight mentioned the use of mannequins.

DISCUSSION

We highlight the potential effectiveness of simulation-based training of paediatric procedural skills in improving patient outcomes, such as reduced mortality rates and incidence of illness/injury.

CONCLUSION

Though the quality of research designs was low, researchers used different simulation modalities and outcome measures and showed a positive impact of SBT(e.g., decreased mortality rates).

Clinical competency development with handmade simulator in highly realistic paediatric dentistry scenarios

INTRODUCTION

The use of simulation is extremely useful in pregraduate students. However, there is a very small number of simulators adapted to paediatric dentistry. A paediatric simulator was created to use in simulated scenarios for paediatric dentistry using an actress in the role of mother. The objectives of the present study were three. First, to analyse the perception of clinical competencies acquired by the students. Second, to examine the realism perceived by the students. Finally, to analyse the influence on the perception of clinical competencies after the integration of a handmade simulator in the Paediatric Dentistry III course.

MATERIALS AND METHODS

Eight clinical scenarios were carried out with a modified Erler Zimmer simulator for children, a professional actress in the role of the mother and two students (in the roles of dentist and assistant) on a paediatric dentistry case of pulpal pathology. The educational intervention was evaluated on 114 students by means of questionnaires with Likert-type answers applied pre- and post-simulation.

RESULTS

The perception of clinical competence in the students increased an average of 0.956 points in relation with the initial clinical evaluation, finding a strong correlation between the perception of subsequent competence and all the perceived realism, with significant statistical differences in all cases. The realism of the simulated participant (professional actress) was the best rated by the students, although not significantly. The realism of the mannequin was positively and strongly correlated with the perceived realism of the cabinet.

CONCLUSION

Simulation using a handmade mannequin with a professional actress in a simulated dental office increased the perception of clinical competence in 4th year dental students and raised the level of overall realism perceived by the student.

A Survey of Academic Neonatologists on Neonatal Electrical Cardioversion and Defibrillation

OBJECTIVE

This study aimed to assess neonatologists' experience and comfort with neonatal electrical cardioversion or defibrillation (EC-D).

STUDY DESIGN

Electronic surveys were distributed to academic neonatologists affiliated with 12 Midwest academic hospitals. Neonatologists were asked about their residency training; years since completing residency; current certification/competency training in the Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support (ACLS), and Neonatal Resuscitation Program (NRP); experiences with EC-D; availability of a pediatric cardiologist; and their comfort levels with such procedures. Standard statistical tests evaluated comfort with EC-D.

RESULTS

Seventy-two out of 180 neonatologists responded to the survey (response rate = 40%). Of them, 98.6% (71), 54.2% (39), and 37.5% (27) maintained current NRP, BLS, and PALS trainings, respectively. Also, 73.6% (n = 53) reported having performed neonatal EC-D. Of those, 50.9% (n = 27) indicated feeling slightly to very uncomfortable performing EC-D. We report a lack of BLS certification being associated with a lack of comfort (odds ratio [OR]: 0.269, 95% confidence interval [CI]: [0.071, 0.936]), and a positive association between a pediatric cardiologist being present and being uncomfortable (OR: 3.722, 95% CI: [1.069, 14.059]). Those reporting greater volume and more recent experience with EC-D report more comfort.

CONCLUSION

Of neonatologists who performed EC-D, half of them reported being uncomfortable. BLS certification and experience are positively associated with comfort in performing EC-D. Simulations to increase training in EC-D should be offered regularly to academic neonatologists.

KEY POINTS

· Most neonatologists have performed EC-D, but many feel uncomfortable with performing EC-D.. · Many do not maintain current certification in BLS, PALS, or ACLS.. · Simulation training in EC-D will increase comfort with EC-D..

3D-printed heart models for hands-on training in pediatric cardiology - the future of modern learning and teaching?

BACKGROUND

This project aims to develop a new concept in training pediatric cardiologists to meet the requirements of interventional cardiac catheterizations today in terms of complexity and importance. This newly developed hands-on training program is supposed to enable the acquisition of certain skills which are necessary when investigating and treating patients in a catheter laboratory.

METHODS

Based on anonymous CT-scans of pediatric patients' digital 3D heart models with or without cardiac defects were developed and printed three-dimensionally in a flexible material visible under X-ray. Hands-on training courses were offered using models of a healthy heart and the most common congenital heart defects (CHD). An evaluation was performed by quantifying fluoroscopy times (FL-time) and a questionnaire.

RESULTS

The acceptance of theoretical and practical contents within the hands-on training was very positive. It was demonstrated that it is possible to master various steps of a diagnostic procedure and an intervention as well as to practice and repeat them independently which significantly reduced FL-time. The participants stated that the hands-on training led to more confidence in interventions on real patients.

CONCLUSION

With the development of a training module using 3D-printed heart models, basic and advanced training in the field of diagnostic cardiac examinations as well as interventional therapies of CHD is possible. The learning effect for both, practical skills and theoretical understanding, was significant which underlines the importance of integrating such hands-on trainings on 3D heart models in education and practical training.

Simulation-Based Emergency Team Training in Pediatrics: A Systematic Review

OBJECTIVES

The rare event of handling critically ill children often challenge the emergency care team. Several studies have investigated effects of simulation-based team training to prepare for such events, but the body of evidence remains to be compiled. We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome.

METHODS

From a search of MEDLINE, Embase, CINAHL, and Cochrane Library, we included studies of team training in emergency pediatric settings with reported clinical performance and patient outcomes. We extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool for randomized trials 2.0 and the Newcastle Ottawa Quality Assessment Scale.

RESULTS

We screened 1926 abstracts and included 79 studies. We identified 15 studies reporting clinical health care professional performance or patient outcomes. Four studies reported survival data, 5 reported time-critical clinical events, 5 reported adherence to guidelines, checklists or tasks, and 2 reported on airway management. Randomized studies revealed improved team performance in simulated reevaluations 2 to 6 months after intervention. A meta-analysis was impossible because of heterogeneous interventions and outcomes. Most included studies had significant methodological limitations.

CONCLUSIONS

Pediatric simulation-based team training improves clinical performance in time-critical tasks and adherence to guidelines. Improved survival was indicated but not concluded because of high risk of bias. Team performance and technical skills improved for at least 2 to 6 months. Future research should include longer-term measures of skill retention and patient outcomes or clinical measures of treatment quality whenever possible.

A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services

OBJECTIVE

Care of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers.

METHODS

We describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method.

RESULTS

Overall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice.

CONCLUSION

Through statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.

Improving Patient- and Family-Centered Communication in Pediatrics: A Review of Simulation-Based Learning

Patient- and family-centered care focuses on relationships among patients, families, and health care providers that are mutually beneficial and improve health care outcomes and provider satisfaction. Building relationships is a key component of the provision of excellent health care and can be taught and enhanced through simulation-based communication skills training. This article reviews the available literature on simulation-based learning as used to improve patient- and family- centered communication in the discipline of pediatrics. In this narrative review, we examine the various methods, theories, and frameworks on which simulation-based learning for communication skills are built with the goal of assisting pediatric providers in using this powerful educational technique. [Pediatr Ann. 2021;50(1):e32-e38.].

Using Simulation in Training Pediatric Residents on Neonatal Abstinence Syndrome Scoring: An Experimental Study

BACKGROUND

Neonatal abstinence syndrome (NAS) is characterized by significant physiological and behavioral signs involving multiple-organ systems in neonates following a prenatal exposure to opioids and other nonopioid drugs. Neonatal abstinence syndrome can result in serious morbidity, and even death, if unrecognized and untreated. The purpose of this study was to develop a simulation model of a standard video training of the Finnegan Neonatal Abstinence Scoring System (FNAS) and investigate the perceptions of comfort and competency of pediatric residents undergoing video or simulation training.

METHODS

Thirty-one pediatric and medicine-pediatric residents participated in this single-blinded randomized intervention study. The experimental group completed demonstrated simulation while the control group received the traditional video instruction. Both groups completed FNAS scoring on a case of a neonate with NAS. The FNAS scores of residents were compared with the scores of 2 expert raters. Pre- and posttraining and preference surveys were obtained from all participants.

RESULTS

Both experimental and control groups scored the FNAS scenario similarly and were also similar to the expert raters. Both groups also reported comparable levels of comfort and competency after the training, though first-year residents reported greater improvement than upper-level residents. The FNAS scores from expert raters were identical for the simulation and video scenarios.

IMPLICATIONS FOR PRACTICE

Although this study showed that a simulation training module can be used as a standardized teaching method to administer the FNAS, it can be cost-prohibitive and daunting to produce. Nursing professionals need to be aware of medical education training around FNAS due to the interdisciplinary nature of care for neonates with NAS. Institutions should consider implementing a diversity of practices and models with an interdisciplinary approach to training assessment of the neonate with NAS.

IMPLICATIONS FOR RESEARCH

A more hands-on, less cost-prohibitive simulation training needs to be developed to teach FNAS administration with a broader range of professionals including interdisciplinary teams of nursing and medical professionals.

Using rapid cycle deliberate practice to improve primary and secondary survey in pediatric trauma

BACKGROUND

Optimal performance of the primary and secondary survey is the foundation of Advance Trauma Life Support care. Despite its importance, not all primary surveys completed at level 1 pediatric trauma centers are performed according to established guidelines (Gala et al., Pediatr Emerg Care 32:756-762, 2016, Carter et al., Resuscitation 84:66-71, 2013). We hypothesize that rapid cycle deliberate practice (RCDP) will improve surgical residents' confidence in performing the primary and secondary survey.

METHODS

We developed a curriculum to teach surgical interns the principles of performing the primary and secondary survey using RCDP. Surveys distributed after each session assessed the impact of the curriculum on learner confidence and perception that this curriculum would benefit patient care. Questions were scored on a 5-point Likert scale. Sixteen surgical interns participated during intern orientation and 100% of the participants completed the post curriculum survey.

RESULTS

Thirteen (81%) of participants agreed or strongly agreed that the simulation would impact future performance in the pediatric trauma bay. The curriculum also significantly improved the confidence of our learners to perform trauma surveys (p < 0.001).

CONCLUSION

This curriculum improves the confidence of junior surgical residents in learning the primary and secondary survey. Most learners enjoyed the session and felt that the curriculum would positively impact their performance.

Relationship between Executive Functions, Mindfulness, Stress, and Performance in Pediatric Emergency Simulations

Over the past decade, high-fidelity medical simulation has become an accepted and widely used teaching method in pediatrics. Both simulation and work in the real conditions of emergency departments are accompanied by stress that affects the executive functions of participants. One of the methods for reducing stress among medical students and healthcare professionals is the practice of mindfulness. The aim of this study was to examine whether executive functions, mindfulness, and stress are related to the technical and non-technical skills of medical students participating in medical simulations in pediatrics. The study included 153 final-year medical students. A total of 306 high-fidelity simulations of life-threatening situations involving children were conducted. Results: Stress and the coping mechanism of the participants were correlated to their skills during pediatric simulations. Some components of mindfulness, such as non-judgment and conscious action, were positively related to the skills of medical team leaders. Executive functions correlated with the non-technical skills and mindfulness of the medical students. Conclusions: Stress, mindfulness, and executive functions modeled the behavior and skills of medical students during pediatric simulations of life-threatening events. Further research in this area may prove whether mindfulness training will improve learning outcomes in pediatric emergency medicine.

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

OBJECTIVES

Pediatric cardiac arrest is a rare event. Its management requires technical (TSs) and nontechnical skills (NTSs). We assessed the effectiveness of a simulation-based training to improve these skills in managing life-threatening pediatric cardiac arrhythmias.

METHODS

Four teams, each composed of 1 pediatric resident, 1 emergency medicine resident, and 2 pediatric nurses, were randomly assigned to the experimental group (EG) participating in 5 video-recorded simulation sessions with debriefing or to the control group (CG) assessed 2 times with video-recorded simulation sessions without debriefing at a 2-week interval. Questionnaires assessed self-reported changes in self-efficacy, stress, and satisfaction about skills. Blinded evaluators assessed changes in leaders' TSs and NTSs during the simulations and the time to initiate cardiopulmonary resuscitation.

RESULTS

After training, stress decreased and satisfaction about skills increased in the EG, whereas it remained the same in the CG (P = 0.014 and P < 0.001, respectively). There was no significant change in self-efficacy. Analyses of video-recorded skills showed significant improvements in TSs and NTSs of the EG leaders after training, but not of the CG leaders (P = 0.026, P = 0.038, respectively). The comparison of the evolution of the 2 groups concerning time to initiate cardiopulmonary resuscitation was not significantly different between the first and last simulation sessions.

CONCLUSIONS

A simulation-based training with debriefing had positive effects on stress and satisfaction about skills of pediatric residents and nurses and on observed TSs and NTSs of the leaders during simulation sessions. A future study should assess the effectiveness of this training in a larger sample and its impact on skills during actual emergencies.

Simulation-based medical training for paediatric residents in Italy: a nationwide survey

BACKGROUND

A prompt start to an appropriate neonatal and paediatric resuscitation is critical to reduce mortality and morbidity. However, residents are rarely exposed to real emergency situations. Simulation-based medical training (SBMT) offers the opportunity to improve medical and non-technical skills in a controlled setting. This survey describes the availability and current use of SBMT by paediatric residents in Italy with the purpose of understanding residents' expectations regarding neonatal and paediatric emergency training, and identifying gaps and potential areas for future implementation.

METHODS

A survey was developed and distributed to Italian residents. SBMT was defined as any kind of training with a mannequin in a contextualised clinically realistic scenario.

RESULTS

The response rate was 14.4%, covering the 71% of Italian paediatric residency programmes. Among them, 88% stated that Out of the 274 residents, 88% stated that they received less than 5 h of SBMT during the past training year, with 66% not participating in any kind of simulation activity. In 62% of the programmes no simulation training facility was available to residents. Among those who received SBMT, 46% used it for procedures and skills, 30% for clinical scenarios, but only 24% of them reported a regular use for debriefing. Of the overall respondents, 93% were interested in receiving SBMT to improve decision-making abilities in complex medical situations, to improve technical/procedural skills, and to improve overall competency in neonatal and paediatric emergencies, including non-technical skills. The main barriers to the implementation of SBMT programmes in Italian paediatric residencies were: the lack of experts (57%), the lack of support from the school director (56%), the lack of organisation in planning simulation centre courses (42%) and the lack of teaching materials (42%).

CONCLUSIONS

This survey shows the scarce use of SBMT during paediatric training programmes in Italy and points out the main limitations to its diffusion. This is a call to action to develop organised SBMT during paediatric residency programs, to train qualified personnel, and to improve the quality of education and care in this field.

Low-Fidelity, In-Situ Pediatric Resuscitation Simulation Improves RN Competence and Self-Efficacy

PROBLEM

ED staff lack adequate exposure to critical pediatric patients to develop competence and confidence in resuscitation scenarios. Simulations of various designs have shown success at increasing health care staff performance and self-efficacy.

METHODS

We developed a nurse-led, low-fidelity in situ simulation of a pediatric sepsis scenario. The primary goal was to improve staff adherence to resuscitation guidelines, as measured by the Clinical Performance Tool, a set of checklists designed to measure adherence to Pediatric Advanced Life Support algorithms by multidisciplinary teams during simulations. The secondary goal was to improve staff confidence, measured by the Confidence Scale, a 5-item Likert-type scale that can measure any psychomotor skill.

RESULTS

A total of 43 RNs participated in 12 simulations over a period of 3 months. Mean Clinical Performance score improved by 74%, from 5.3 to 9.2 (P < 0.001). Mean confidence score for RNs improved by 56%, from 2.48 (standard deviation [SD] 0.83) to 3.88 (SD 0.66) (P < 0.001). Several systems issues were identified and addressed by multidisciplinary teams, such as increasing respiratory therapist response to the emergency department and updating of the Broselow cart.

DISCUSSION

In situ low-fidelity simulations led by RNs contributed to significant improvement in adherence to resuscitation guidelines and in staff confidence. The simulation design had minimal impact on staffing and budget and enabled identification and correction of systems issues.

A Scoping Review of Medical Education Research in Neurosurgery

BACKGROUND

Little is known about the state of medical education (ME) research in neurosurgery. As ME started to develop in neurosurgery in recent years, it is important to understand the current status and develop the theory for advancement in neurosurgery. The aim of this study was to undertake a scoping review of neurosurgery literature on ME research.

METHODS

MEDLINE, SCOPUS, and PubMed databases were searched. Inclusion criteria were full-text articles in English published from January 2006 to December 2017. Research aspects included country of publication, annual number of publications, journal types, type of participants, frequently researched topics, and research design. Search terms included neurosurgery, medical education, teaching, training, learning, and curriculum.

RESULTS

A total of 9863 references were found across 3 databases. After duplicate removal and further screening, 533 references remained for coding analysis. ME research activity in neurosurgery is increasing and commonly observed in Western countries. Identified articles were mostly quantitative, with curriculum, assessment (especially simulation), and teaching and learning being the most dominant research themes.

CONCLUSIONS

This study highlights the need for enhanced quantity and quality of ME research in neurosurgery. It identifies areas of highest priority and aspects to be improved and provides us with a rationale for future development in ME in neurosurgery. These findings reveal future education research direction and programmatic research areas, while also establishing a benchmark to assess changes in educational scholarship over time.

Performance comparison in Pediatric Fundamental Critical Care Support among staff from the USA versus those from resource-limited countries

OBJECTIVE

This study aimed to evaluate the performance of participants in the USA compared with international participants taking the Pediatric Fundamental Critical Care Support (PFCCS) course, and the significance of training for resource-limited environments.

METHODS

PFCCS courses were conducted in the USA, El Salvador, Haiti, Kenya, and Nepal between January 2011 and July 2013. All of the participants took pre- and post-tests. We compared the performance of these tests between international and USA participants. All participants answered a post-course survey to evaluate the didactic lectures and skill stations.

RESULTS

A total of 244 participants took the PFCCS course, comprising 71 from the USA, 68 from Kenya, 37 from Haiti, 48 from Nepal, and 20 from El Salvador. The mean pre-test score of USA participants (50.6%) was significantly higher than that of international participants (44.7%). There was no significant difference in the post-test score between USA and international participants (78.6% versus 81.4%). There was a significant difference between pre- and post-test scores. There was better appreciation of the course content by the USA participants.

CONCLUSION

International course takers without prior pediatric intensive care training have similar test scores to USA participants suggesting comparable efficacy.

Transition of pediatric patients with an Auto-inflammatory Disease: an alternative version of the Daedaulus and Icarus myth

Progress in the pediatric Auto-inflammatory Diseases (AIDs) has led to improved long-term outcome and the increased pool of pediatric patients who require lifelong monitoring. Implementation of a successful stepwise transition in patients with AIDs denotes the presence of a structured flexible and individualized policy that ensues the stepwise move from family-based pediatric care to adult patient one. This process aims to equip the young adult with self-management skills and the ability to enjoy life even under the burden of a chronic disease. Transition, thus, is a continuously evolutionary process that assists adolescents and young adults with an AID to move into a future that their predecessors with similar diseases never needed to experience. This review, using the myth of Daedalus and Icarus as a scaffold, presents the contemporary profile of the adolescent patient, comments on the evidence derived from Transition recommendations, and emphasizes the need of periodic quantitative assessments to assess the efficacy of the Transition plan. Upon the completion of the transfer to the Adult Center, monitoring of the patient’s active participation will support his/her engagement in the new setting.

Not just trust: factors influencing learners' attempts to perform technical skills on real patients

CONTEXT

As part of their training, physicians are required to learn how to perform technical skills on patients. The previous literature reveals that this learning is complex and that many opportunities to perform these skills are not converted into attempts to do so by learners. This study sought to explore and understand this phenomenon better.

METHODS

A multi-phased qualitative study including ethnographic observations, interviews and focus groups was conducted to explore the factors that influence technical skill learning. In a tertiary paediatric emergency department, staff physician preceptors, residents, nurses and respiratory therapists were observed in the delivery and teaching of technical skills over a 3-month period. A constant comparison methodology was used to analyse the data and to develop a constructivist grounded theory.

RESULTS

We conducted 419 hours of observation, 18 interviews and four focus groups. We observed 287 instances of technical skills, of which 27.5% were attempted by residents. Thematic analysis identified 14 factors, grouped into three categories, which influenced whether residents attempted technical skills on real patients. Learner factors included resident initiative, perceived need for skill acquisition and competing priorities. Teacher factors consisted of competing priorities, interest in teaching, perceived need for residents to acquire skills, attributions about learners, assessments of competency, and trust. Environmental factors were competition from other learners, judgement that the patient was appropriate, buy-in from team members, consent from patient or caregivers, and physical environment constraints.

CONCLUSIONS

Our findings suggest that neither the presence of a learner in a clinical environment nor the trust of the supervisor is sufficient to ensure the learner will attempt a technical skill. We characterise this phenomenon as representing a pool of opportunities to conduct technical skills on live patients that shrinks to a much smaller pool of technical skill attempts. Learners, teachers and educators can use this knowledge to maximise the number of attempts learners make to perform technical skills on real patients.

A Randomized Educational Interventional Trial of Spaced Education During a Pediatric Rotation

OBJECTIVE

Spacing of educational material over time has been shown to improve learning efficiency and long-term knowledge retention. We evaluated the impact of adding a spaced education curriculum to a month-long pediatric rotation.

METHODS

This was a randomized controlled educational intervention trial of residents on a rotation in a pediatric emergency department. Participants were randomized to the standard curriculum or the standard curriculum with integrated spaced education. The intervention used an automated platform to electronically deliver questions to user e-mail or mobile devices and provided instant feedback. Our primary outcome was proportion of correctly answered questions following the rotation. Our secondary outcomes included test performance at 3 months, change in clinical confidence, and satisfaction with the spaced learning. Learner opinion of the platform was assessed by postrotation survey.

RESULTS

Of 194 eligible trainees, 122 were enrolled and randomized. A total of 107 of the enrolled residents (88%) completed the immediate postrotation assessment, 48 of whom received spaced education. Sixty residents completed the 3-month follow-up. There were no differences between the control and intervention groups in baseline knowledge. The intervention group performed better than the control group on the postrotation assessment (mean difference = 5.4%, 95% confidence interval = 0.1-10.7) when controlled for didactic attendance and clinical exposure. Change in confidence did not differ between groups. Eighty-seven percent of spaced education learners would participate in a similar model in the future.

CONCLUSION

Spaced education during a pediatric emergency medicine rotation is an effective adjunct to a standard curriculum. Participants showed improvement on postrotation knowledge performance and enjoyed this educational approach.

Evaluation of a Pilot Project to Introduce Simulation-Based Team Training to Pediatric Surgery Trauma Room Care

Introduction. Several studies in pediatric trauma care have demonstrated substantial deficits in both prehospital and emergency department management. Methods. In February 2015 the PAEDSIM collaborative conducted a one and a half day interdisciplinary, simulation based team-training course in a simulated pediatric emergency department. 14 physicians from the medical fields of pediatric surgery, pediatric intensive care and emergency medicine, and anesthesia participated, as well as four pediatric nurses. After a theoretical introduction and familiarization with the simulator, course attendees alternately participated in six simulation scenarios and debriefings. Each scenario incorporated elements of pediatric trauma management as well as Crew Resource Management (CRM) educational objectives. Participants completed anonymous pre- and postcourse questionnaires and rated the course itself as well as their own medical qualification and knowledge of CRM. Results. Participants found the course very realistic and selected scenarios highly relevant to their daily work. They reported a feeling of improved medical and nontechnical skills as well as no uncomfortable feeling during scenarios or debriefings. Conclusion. To our knowledge this pilot-project represents the first successful implementation of a simulation-based team-training course focused on pediatric trauma care in German-speaking countries with good acceptance.