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Tofil NM, Gaither SL, Cohen C, Norwood C, Zinkan JL, Raju SS, Rutledge C. Observational Study on the Effect of Duration from Pediatric Advanced Life Support (PALS) Certification on PALS Performance in Pediatric Interns in Simulated Cardiopulmonary Arrest. J Pediatr Intensive Care 2023; 12:271-277. [PMID: 37970138 PMCID: PMC10631835 DOI: 10.1055/s-0041-1731787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/29/2021] [Indexed: 10/20/2022] Open
Abstract
Pediatric advanced life support (PALS) training is critical for pediatric residents. It is unclear how well PALS skills are developed during this course or maintained overtime. This study evaluated PALS skills of pediatric interns using a validated PALS performance score following their initial PALS certification. All pediatric interns were invited to a 45-minute rapid cycle deliberate practice (RCDP) training session following their initial PALS certification from July 2017 to June 2019. The PALS score and times for key events were recorded for participants prior to RCDP training. We then compared performance scores for those who took PALS ≥3 months, between 3 days to 3 months and 3 days after PALS. There were 72 participants, 30 (of 30) in 3 days, 18 in 3 days to 3 months, and 24 in ≥3 months groups (42 total of 52 residents, 81%). The average PALS performance score was 53 ± 20%. There was no significant difference between the groups (3 days, 53 ± 15%; 3 days-3 months, 51 ± 19%; ≥3 months, 54 ± 26%, p = 0.922). Chest compressions started later in the ≥3 months groups compared with the 3 days or ≤3 months groups ( p = 0.036). Time to defibrillation was longer in the 3 days group than the other groups ( p = 0.008). Defibrillation was asked for in 3 days group at 97%, 73% in 3 days to 3 months and 68% in ≥3 months groups. PALS performance skills were poor in pediatric interns after PALS certification and was unchanged regardless of when training occurred. Our study supports the importance of supplemental resuscitation training in addition to the traditional PALS course.
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Affiliation(s)
- Nancy M. Tofil
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Stacy L. Gaither
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Charli Cohen
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Carrie Norwood
- Children's of Alabama, Pediatric Simulation Center, Birmingham, Alabama, United States
| | - Jerry Lynn Zinkan
- Children's of Alabama, Pediatric Simulation Center, Birmingham, Alabama, United States
| | - Sai S. Raju
- Department of Pediatrics, University of Texas at Austin, Austin, Texas, United States
| | - Chrystal Rutledge
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Norwood CM, Zinkan JL, Perry SH, Tofil NM, Gaither SL, Rutledge C. Professional Success: Utilizing Simulation to Remediate and Retain Nursing Staff. J Nurses Prof Dev 2023; 39:322-327. [PMID: 37902633 DOI: 10.1097/nnd.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Nursing education focuses on nursing theory and the ability to perform tasks. There is a lack of education related to prioritization of nursing tasks. Therefore, new nurses transitioning into their roles sometimes struggle and, as a result, leave their units or, often enough, our facility. We developed a Professional Success Program that includes cognitive prioritization exercises and simulation scenarios to assist these nurses. After utilizing the program, our facility has seen an increase in nurse retention.
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Waddell K, Gaither SL, Rockwell N, Tofil NM, Rutledge C. The Impact of a Multifaceted Simulation Education and Feedback Program for Community Emergency Departments on Pediatric Diabetic Ketoacidosis Management. Pediatr Emerg Care 2023; 39:413-417. [PMID: 37163689 DOI: 10.1097/pec.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We sought to determine if general emergency departments (GEDs) were managing pediatric diabetic ketoacidosis (DKA) correctly and if management could be improved using a multilayered educational initiative. We hypothesized that a multifaceted program of in situ simulation education and formal feedback on actual patient management would improve community GED management of pediatric DKA. METHODS This study combined a prospective simulation-based performance evaluation and a retrospective chart review. A community outreach simulation education initiative was developed followed by a formal patient feedback process. RESULTS Fifteen hospitals participated in simulation sessions and the feedback process. All hospitals were scored for readiness to provide care for critically ill pediatric patients using the Emergency Medical Services for Children (EMSC) Pediatric Readiness Assessment. Six of the 15 have had a second hospital visit that included a DKA scenario with an average performance score of 60.3%. A total of 158 pediatric patients with DKA were included in the chart review. The GEDs with higher patient volumes provided best practice DKA management more often (63%) than those with lower patient volumes (40%). Participating in a DKA simulated scenario showed a trend toward improved care, with 47.2% before participation and 68.2% after participation ( P = 0.091). Participating in the formal feedback process improved best practice management provided to 68.6%. Best practice management was further improved to 70.3% if the GED participated in both a DKA simulation and the feedback process ( P = 0.04). CONCLUSIONS A multifaceted program of in situ simulation education and formal feedback on patient management can improve community GED management of pediatric patients with DKA.
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Affiliation(s)
- Kristen Waddell
- From the Pediatric Intensive Care Unit, Children's of Alabama, Birmingham, AL
| | - Stacy L Gaither
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas Rockwell
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nancy M Tofil
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Chrystal Rutledge
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Schmit EO, Molina AL, Stoops C, Rahman AF, Dye C, Tofil NM. Infant Safe Sleep Knowledge, Attitudes, and Behaviors by Physicians at an Academic Children's Hospital. Clin Pediatr (Phila) 2022. [PMID: 35762067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Sudden unexpected infant death (SUID) is the leading cause of death for infants. Physician advice on safe sleep is an important source of information for families. We sought to evaluate the safe sleep knowledge, attitudes, and behaviors of physicians by distributing a cross-sectional survey at a freestanding children's hospital. The survey included demographics, knowledge items, attitudinal assessment, and frequency of providing safe sleep guidance. Multivariable linear regression and logistic regression were used to evaluate associations between variables. 398 physicians were surveyed with 124 responses (31%). Females, those who received safe sleep training, and those who see infants in daily practice had higher knowledge scores. Physicians with higher knowledge scores had more positive attitudes toward safe sleep and provided safe sleep education to patients more often. Our study underlies the importance of education and repeated exposure in forming positive attitudes toward safe sleep recommendations and leads to increased provision of safe sleep guidance.
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Affiliation(s)
- Erinn O Schmit
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adolfo L Molina
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christine Stoops
- Division of Neonatology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akm Fazlur Rahman
- Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Candice Dye
- Division of Academic General Pediatrics, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nancy M Tofil
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
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Loberger JM, Waddell KC, Prabhakaran P, Jones RM, Lawrence MV, Bittles LA, Hill AM, O'Sheal SE, Armstrong AW, Thomas CL, Daniel LH, Tofil NM, Sasser WC, Richter RP, Rutledge CL. Pediatric Ventilation Liberation: Bundled Extubation Readiness and Analgosedation Pathways Decrease Mechanical Ventilation Duration and Benzodiazepine Exposure. Respir Care 2022; 67:1385-1395. [PMID: 35820701 PMCID: PMC10408364 DOI: 10.4187/respcare.09942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration. METHODS This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways. RESULTS In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; P = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; P = .42). No difference in unplanned extubation (P > .99) or extubation failure rates (P = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; P = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; P < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; P = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; P = .14) was demonstrated. CONCLUSIONS A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.
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Affiliation(s)
- Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Kristen C Waddell
- Department of Nursing Services, Children's of Alabama, Birmingham, Alabama
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ryan M Jones
- Department of Respiratory Therapy, Children's of Alabama, Birmingham, Alabama
| | - Maggie V Lawrence
- Department of Nursing Services, Children's of Alabama, Birmingham, Alabama
| | - Leah A Bittles
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amy M Hill
- Department of Respiratory Therapy, Children's of Alabama, Birmingham, Alabama
| | - Shannon E O'Sheal
- Department of Nursing Services, Children's of Alabama, Birmingham, Alabama
| | - Andrea W Armstrong
- Department of Nursing Services, Children's of Alabama, Birmingham, Alabama
| | - Christy L Thomas
- Department of Respiratory Therapy, Children's of Alabama, Birmingham, Alabama
| | - Laura H Daniel
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama
| | - Nancy M Tofil
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - William C Sasser
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert P Richter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chrystal L Rutledge
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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Bjornstad EC, Cutter G, Guru P, Menon S, Aldana I, House S, M Tofil N, St Hill CA, Tarabichi Y, Banner-Goodspeed VM, Christie AB, Mohan SK, Sanghavi D, Mosier JM, Vadgaonkar G, Walkey AJ, Kashyap R, Kumar VK, Bansal V, Boman K, Sharma M, Bogojevic M, Deo N, Retford L, Gajic O, Gist KM. SARS-CoV-2 infection increases risk of acute kidney injury in a bimodal age distribution. BMC Nephrol 2022; 23:63. [PMID: 35144572 PMCID: PMC8831033 DOI: 10.1186/s12882-022-02681-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/18/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hospitalized patients with SARS-CoV2 develop acute kidney injury (AKI) frequently, yet gaps remain in understanding why adults seem to have higher rates compared to children. Our objectives were to evaluate the epidemiology of SARS-CoV2-related AKI across the age spectrum and determine if known risk factors such as illness severity contribute to its pattern. METHODS Secondary analysis of ongoing prospective international cohort registry. AKI was defined by KDIGO-creatinine only criteria. Log-linear, logistic and generalized estimating equations assessed odds ratios (OR), risk differences (RD), and 95% confidence intervals (CIs) for AKI and mortality adjusting for sex, pre-existing comorbidities, race/ethnicity, illness severity, and clustering within centers. Sensitivity analyses assessed different baseline creatinine estimators. RESULTS Overall, among 6874 hospitalized patients, 39.6% (n = 2719) developed AKI. There was a bimodal distribution of AKI by age with peaks in older age (≥60 years) and middle childhood (5-15 years), which persisted despite controlling for illness severity, pre-existing comorbidities, or different baseline creatinine estimators. For example, the adjusted OR of developing AKI among hospitalized patients with SARS-CoV2 was 2.74 (95% CI 1.66-4.56) for 10-15-year-olds compared to 30-35-year-olds and similarly was 2.31 (95% CI 1.71-3.12) for 70-75-year-olds, while adjusted OR dropped to 1.39 (95% CI 0.97-2.00) for 40-45-year-olds compared to 30-35-year-olds. CONCLUSIONS SARS-CoV2-related AKI is common with a bimodal age distribution that is not fully explained by known risk factors or confounders. As the pandemic turns to disproportionately impacting younger individuals, this deserves further investigation as the presence of AKI and SARS-CoV2 infection increases hospital mortality risk.
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Affiliation(s)
- Erica C Bjornstad
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 516, Birmingham, AL, 35233, USA.
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Shina Menon
- Seattle Children's Hospital, Seattle, WA, USA
| | - Isabella Aldana
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 516, Birmingham, AL, 35233, USA
| | - Scott House
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 516, Birmingham, AL, 35233, USA
| | - Nancy M Tofil
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Catherine A St Hill
- Allina Health (Abbott Northwestern Hospital, United Hospital, Mercy Hospital), Minneapolis, MN, USA
| | | | | | | | | | | | - Jarrod M Mosier
- University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | | | | | | | | | | | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, IL, USA
| | | | | | | | - Lynn Retford
- Society of Critical Care Medicine, Mount Prospect, IL, USA
| | | | - Katja M Gist
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Surapa Raju S, Tofil NM, Gaither SL, Norwood C, Zinkan JL, Godsey V, Aban I, Xue Y, Rutledge C. The Impact of a 9-Month Booster Training Using Rapid Cycle Deliberate Practice on Pediatric Resident PALS Skills. Simul Healthc 2021; 16:e168-e175. [PMID: 33370083 DOI: 10.1097/sih.0000000000000538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The impact of booster training on pediatric resuscitation skills is not well understood. Rapid cycle deliberate practice (RCDP) to supplement pediatric advanced life support (PALS) training is beginning to be used to improve resuscitation skills. We tested the impact of booster RCDP training performed at 9 months after initial RCDP training on pediatric resuscitation skills of pediatric residents. OBJECTIVE This study evaluated the impact of a 9-month RCDP booster training on PALS skills compared with usual practice debriefing (plus/delta) after an initial RCDP training session for PALS-certified pediatric interns. METHODS All pediatric interns at a single institution were invited to a 45-minute RCDP training session after their initial PALS certification. The PALS performance score and times for key events were recorded for participants immediately before and after the RCDP training as well as 6, 9, and 12 months after the RCDP training. Learners were randomized to an RCDP intervention and usual practice (plus/delta) group. The intervention group received booster RCDP training after their 9-month assessment. RESULTS Twenty eight of 30 residents participated in the initial training with 22 completing randomization at 9 months. There was no significant difference in 12-month PALS median performance scores after the booster training between the intervention and usual practice groups (83% vs. 94%, P = 0.31). There was significant improvement in PALS performance score from 51 ± 27% pre-initial RCDP assessment to 93 ± 5% post-initial RCDP training (P < 0.001). There were significant improvements in individual skills from pre- to post-initial RCDP testing, including time to verbalize pulseless, start compressions, and attach defibrillation pads (P < 0.001). CONCLUSIONS Rapid cycle deliberate practice booster training versus plus/delta training at 9-month post-initial RCDP training did not alter 12-month performance. However, RCDP is effective at improving PALS performance skills, and this effect is maintained at 6, 9, and 12 months. Our study supports the importance of supplemental resuscitation training in addition to the traditional PALS course.
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Affiliation(s)
- Sai Surapa Raju
- From the Division of Critical Care (S.S.R., N.M.T., S.L.G., V.G., C.R.), Department of Pediatrics, University of Alabama at Birmingham; Pediatric Simulation Center (C.N., J.L.Z.), Children's of Alabama; and Department of Biostatistics (Y.X.), University of Alabama at Birmingham, Birmingham, AL
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Loberger JM, Jones RM, Hill AM, O'Sheal SE, Thomas CL, Tofil NM, Prabhakaran P. Challenging Convention: Daytime Versus Nighttime Extubation in the Pediatric ICU. Respir Care 2021; 66:777-784. [PMID: 33563792 PMCID: PMC9994120 DOI: 10.4187/respcare.08494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The majority of pediatric extubations occur during day shift hours. There is a time-dependent relationship between mechanical ventilation duration and complications. It is not known if extubation shift (day vs night) correlates with pediatric extubation outcomes. Pediatric ventilation duration may be unnecessarily prolonged if extubation is routinely delayed until day shift hours. METHODS We hypothesized that extubation failure would not correlate with shift of extubation and that ventilation duration at first extubation and that length of stay in the pediatric ICU (PICU) would be shorter for children extubated at night. This was a retrospective cohort study within one tertiary care, 24-bed, academic PICU. RESULTS 582 ventilation encounters were included, representing 517 unique subjects. Status epilepticus was a more common diagnosis among night shift extubations (P = .005), whereas surgical airway conditions were more common among day shift extubations (P = .02). Mechanical ventilation duration at first extubation (37.6 vs 62.5 h, P < .001) and length of stay in the PICU (2.8 vs 4.5 d, P < .001) were shorter for night shift extubations. The extubation failure rate was 10.3% for day shift and 8.1% for night shift (P = .40). Logistic regression modeling at the level of the unique subject indicated that extubation shift was not associated with extubation failure (P = .44). The majority of re-intubation events occurred on the shift opposite of extubation. There was no difference in complications according to shift of re-intubation (P = .72). CONCLUSIONS Extubation failure was not independently associated with extubation shift in this single-center study. Ventilation liberation should be considered at the first opportunity dictated by clinical data and patient-specific factors rather than by the time of day at centers with similar resources.
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Affiliation(s)
- Jeremy M Loberger
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Ryan M Jones
- Department of Respiratory Therapy, Children's Hospital of Alabama, Birmingham, Alabama
| | - Amy M Hill
- Department of Respiratory Therapy, Children's Hospital of Alabama, Birmingham, Alabama
| | - Shannon E O'Sheal
- Department of Nursing, Children's Hospital of Alabama, Birmingham, Alabama
| | - Christy L Thomas
- Department of Respiratory Therapy, Children's Hospital of Alabama, Birmingham, Alabama
| | - Nancy M Tofil
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Priya Prabhakaran
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Dye C, Surapa Raju SK, Dy A, Gaither SL, Tofil NM. Suicide Simulation in Primary Care. South Med J 2021; 114:129-132. [PMID: 33655304 DOI: 10.14423/smj.0000000000001217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This project was developed because residents need to gain knowledge and experience in promptly recognizing patients with suicidal ideation. Our study allowed pediatric interns the opportunity to manage a simulated 16-year-old actively suicidal patient in the resident continuity clinic for a well-child visit. METHODS During their first year, each resident receives simulation training. The simulation scenario for this study involves the use of a standardized patient (SP). Sessions take place in the pediatric simulation center and are recorded for observation and review. The scenario was scripted and piloted to ensure standardization in educational intervention. Postscenario, participants have a nonjudgmental debriefing with the attending physician and the SP. An anonymous survey is completed after training. Enrollment was June 2016-September 2019, with two to three 1-hour cases monthly. RESULTS Seventy-one postgraduate year-1 residents participated. Sixty-one residents left the suicidal patient alone/unobserved. Fifteen participants never learned of the intent of suicide during their initial intake with the patient but believed that she was depressed. The mean time to ask about suicidal ideation, when applicable, was 8:32 minutes (standard deviation 4:10 minutes, range 2:15-24:48 minutes). Common learning themes included realistic exposure to an actively suicidal patient and simulation debriefing/direct feedback from the SP. CONCLUSIONS Practicing this crucial but somewhat rare primary care mental health emergency for all interns was possible when structured monthly. Feedback was extremely positive, with learners' feeling more prepared postsimulation. Our simulation experience also allows supervisors to assess intern's individual abilities to communicate in a difficult patient scenario which is an important physician competency as defined by the Accreditation Council for Graduate Medical Education.
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Affiliation(s)
- Candice Dye
- From the Department of Pediatrics, Division of General Pediatrics and the Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, and the Division of Family Practice, Medical University of South Carolina, Charleston
| | - Sai Krishna Surapa Raju
- From the Department of Pediatrics, Division of General Pediatrics and the Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, and the Division of Family Practice, Medical University of South Carolina, Charleston
| | - Abigail Dy
- From the Department of Pediatrics, Division of General Pediatrics and the Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, and the Division of Family Practice, Medical University of South Carolina, Charleston
| | - Stacy L Gaither
- From the Department of Pediatrics, Division of General Pediatrics and the Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, and the Division of Family Practice, Medical University of South Carolina, Charleston
| | - Nancy M Tofil
- From the Department of Pediatrics, Division of General Pediatrics and the Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, and the Division of Family Practice, Medical University of South Carolina, Charleston
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Duff JP, Bhanji F, Lin Y, Overly F, Brown LL, Bragg EA, Kessler D, Tofil NM, Bank I, Hunt EA, Nadkarni V, Cheng A. Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback. Pediatr Emerg Care 2021; 37:133-137. [PMID: 33651758 DOI: 10.1097/pec.0000000000002359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time. METHODS We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation. RESULTS There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05). CONCLUSIONS There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.
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Affiliation(s)
| | | | - Yiqun Lin
- University of Calgary, Calgary, Canada
| | | | | | | | - David Kessler
- Columbia University Vagelos College of Physicians and Surgeons New York, NY
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Abstract
OBJECTIVE To evaluate the knowledge of obtaining travel histories in medical students and interns. METHODS Medical students and interns participated in a high-fidelity pediatric simulation with two cases (malaria or typhoid fever) that hinged on travel history. After the simulation, appropriate methods of obtaining travel histories were discussed. Participants completed surveys regarding their previous education and comfort with obtaining travel histories. If and how a travel history was obtained was derived from simulation observation. RESULTS From June 2016 to July 2017, 145 medical trainees participated in 24 simulation sessions; 45% reported no prior training in obtaining travel histories. Participants asked for a travel history in all but 2 simulations; however, in 9 of 24 simulations (38%), they required prompting by either a simulation confederate or laboratory results. Participants were more comfortable diagnosing/treating conditions acquired from US domestic travel than from international travel (32.9% vs 22.4%, P < 0.001). Previous education in obtaining travel histories and past international travel did not significantly influence the level of comfort that participants felt with travel histories. CONCLUSIONS This study highlights the lack of knowledge regarding the importance of travel histories as part of basic history taking. Medical students and interns had low levels of comfort in obtaining adequate travel histories and diagnosing conditions acquired from international travel.
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Affiliation(s)
- Shaundra Blakemore
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
| | - Meghan E Hofto
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
| | - Nipam Shah
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
| | - Stacy L Gaither
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
| | - Pranaya Chilukuri
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
| | - Nancy M Tofil
- From the Department of Pediatrics, the Pediatric Research Office, and the School of Medicine, University of Alabama at Birmingham
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Wise KM, Zinkan JL, Rutledge C, Gaither S, Norwood C, Tofil NM. Development of a "First Five Minutes" Program to Improve Staff Response to Pediatric Codes. Am J Crit Care 2020; 29:233-236. [PMID: 32355972 DOI: 10.4037/ajcc2020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delayed or inadequate cardiopulmonary resuscitation during cardiopulmonary arrest is associated with adverse resuscitation outcomes in pediatric patients. Therefore, a "First Five Minutes" program was developed to train all inpatient acute care nurses in resuscitation skills. The program focused on steps to take during the first 5 minutes. OBJECTIVE To improve response of bedside personnel in the first few minutes of a cardiopulmonary emergency. METHODS A simulation-based in situ educational program was developed that focused on the components of the American Heart Association's "Get With the Guidelines" recommendations. The program was implemented in several phases to improve instruction and focus on necessary skills. RESULTS The program garnered positive feedback from participants and was deemed helpful in preparing nurses and other staff members to respond to a patient in cardiopulmonary arrest. Time to chest compressions improved after training, and postintervention responses to questions regarding future code performance indicated participant recognition of the priority of the interventions addressed, such as backboard use, timely initiation of chest compressions, and timely administration of medications. Preliminary data show staff improvements in mock code performance. CONCLUSIONS The First Five Minutes program has proved to be a successful educational initiative and is expected to be continued indefinitely, with additional phases incorporated as needed. A rigorous study on best teaching methods for the program is planned.
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Affiliation(s)
- Kandi M. Wise
- Kandi M. Wise, J. Lynn Zinkan, and Carrie Norwood are educators and Stacy Gaither is director of research and simulation education for the Pediatric Simulation Center at Children’s of Alabama (Department of Pediatrics, University of Alabama at Birmingham), Birmingham, Alabama
| | - J. Lynn Zinkan
- Kandi M. Wise, J. Lynn Zinkan, and Carrie Norwood are educators and Stacy Gaither is director of research and simulation education for the Pediatric Simulation Center at Children’s of Alabama (Department of Pediatrics, University of Alabama at Birmingham), Birmingham, Alabama
| | - Chrystal Rutledge
- Chrystal Rutledge is co-medical director of the Pediatric Simulation Center at Children’s of Alabama and an assistant professor of pediatrics at the University of Alabama at Birmingham
| | - Stacy Gaither
- Stacy Gaither is director of research and simulation education for the Pediatric Simulation Center at Children’s of Alabama (Department of Pediatrics, University of Alabama at Birmingham), Birmingham, Alabama
| | - Carrie Norwood
- Kandi M. Wise, J. Lynn Zinkan, and Carrie Norwood are educators and Stacy Gaither is director of research and simulation education for the Pediatric Simulation Center at Children’s of Alabama (Department of Pediatrics, University of Alabama at Birmingham), Birmingham, Alabama
| | - Nancy M. Tofil
- Nancy M. Tofil is medical director of the Pediatric Simulation Center at Children’s of Alabama and professor of pediatrics, University of Alabama at Birmingham
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Tofil NM, Rutledge C, Surapa Raju SK, Zinkan JL, Norwood C, Gaither S, Eberhardt A. Novel paediatric pericardiocentesis simulator: a collaboration between the Departments of Pediatrics and Biomedical Engineering. BMJ STEL 2020; 6:41-42. [DOI: 10.1136/bmjstel-2018-000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 11/03/2022]
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Swinger ND, Rutledge C, Gaither S, Youngblood AQ, Zinkan JL, Tofil NM. Rapid cycle deliberate practice improves and sustains paediatric resident PALS performance. BMJ STEL 2019; 6:257-261. [DOI: 10.1136/bmjstel-2019-000483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 11/04/2022]
Abstract
ObjectivesPaediatric cardiopulmonary arrest resuscitation is a critically important skill but infrequently used in clinical practice. Therefore, resuscitation knowledge relies heavily on formal training which is vulnerable to rapid knowledge decay. We evaluate knowledge and skill retention post-training using rapid cycle deliberate practice (RCDP).DesignPilot, non-blinded, single-arm study.SettingPediatric Simulation Center at Children’s of Alabama.Participants42 paediatric residents at a large, tertiary care, academic children’s hospital were enrolled in this simulation-based resuscitation study.InterventionsEach participant led a 7 min preintervention arrest scenario as a baseline test. After testing, participants were trained individually in the paediatric advanced life support (PALS) skills necessary for resuscitation of a patient in pulseless electrical activity and ventricular fibrillation using RCDP—a simulation method using frequent expert feedback and repeated opportunities for the learner to incorporate new learning. Immediately post-training, participants were retested as leaders of a different paediatric arrest scenario. 3 months post-training participants returned to complete a final simulation scenario.Main outcome measuresTo evaluate knowledge and skill retention following PALS training.ResultsPreintervention data demonstrated poor baseline resident performance with an average PALS score of 52%. Performance improved to 94% immediately post-training and this improvement largely persisted at 3 months, with an average performance of 81%. In addition to improvements in performance, individual skills improved including communication, recognition of rhythms, early chest compressions and rapid administration of epinephrine or defibrillation.ConclusionsRCDP training was associated with significant improvements in resident performance during simulated paediatric resuscitation and high retention of those improvements.
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Bernard DW, White ML, Tofil NM, Jolliffe C, Youngblood A, Zinkan JL, Gaither SL, Peterson DT, Yuan YY. A Simulation Course Focusing on Forensic Evidence Collection Improves Pediatric Knowledge and Standardizes Curriculum for Child Abuse. South Med J 2019; 112:487-490. [PMID: 31485588 DOI: 10.14423/smj.0000000000001014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Our hypothesis was that pediatric residents and medical students who participated in a structured forensic evidence collection course would have improved knowledge of prepubertal evidence collection practices and pubertal genital anatomy. METHODS The course curriculum included a forensic evidence collection video created by the sexual assault nurse examiner directors. After watching the video, the participants simulated forensic evidence collection using forensic evidence collection kits and chain of evidence protocols in a hybrid simulation setting under the supervision of a pediatric sexual assault nurse examiner. The participants completed a multiple-choice test and a fill-in-the-blank anatomical diagram test before and after the course. RESULTS Of an eligible 48 participants, 42 completed the course; therefore, our participant response rate was 87.5%. There was significant improvement in knowledge, with an average pretest score of 62% ± 20% and the average posttest score of 86% ± 9% (P < 0.001). Qualitative evaluations were overwhelmingly positive, with consistent scoring of 6/6 in a 6-point agree scale. Learning themes, which emerged from open-ended questions on the evaluations, included knowledge gained on evidence collection processes (n = 26), how to appropriately interact with abused patients (n = 8), hands-on nature of the experience and the benefits of walking through the examination (n = 7), and pubertal genital anatomy knowledge (n = 3). Participants suggested that more instruction on anatomy would be helpful. CONCLUSIONS We found that pediatric residents' and medical students' knowledge of pediatric sexual abuse may be improved with a short simulation course focusing on forensic evidence collection.
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Affiliation(s)
- David W Bernard
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Marjorie Lee White
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Nancy M Tofil
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Chris Jolliffe
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Amber Youngblood
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - J Lynn Zinkan
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Stacy L Gaither
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Dawn Taylor Peterson
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Yih Ying Yuan
- From the Department of Pediatrics and Medical Education, University of Alabama at Birmingham, Birmingham, Children's of Alabama, Birmingham, and the Department of Pediatrics, University of Texas Southwestern, Dallas
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Sasser WC, Sims AN, Loberger JM, Tofil NM, Prabhakaran P. Clinically-relevant cardiopulmonary interactions for the pediatric intensivist. Minerva Pediatr 2018; 71:76-81. [DOI: 10.23736/s0026-4946.18.05338-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y, Chatfield J, Brown LL, Hunt EA. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: A randomized simulation-based clinical trial. Resuscitation 2018; 132:33-40. [PMID: 30149088 DOI: 10.1016/j.resuscitation.2018.08.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/09/2018] [Accepted: 08/22/2018] [Indexed: 11/15/2022]
Abstract
AIM To determine if integrating a trained CPR Coach into resuscitation teams can improve CPR quality during simulated pediatric cardiopulmonary arrest (CPA). METHODS We conducted a multicenter, prospective, randomized trial. An 18-minute simulated CPA scenario was run for resuscitation teams comprised of CPR-certified professionals from four International Network for Simulation-based Pediatric Innovation, Research & Education (INSPIRE) institutions. Forty teams (200 participants) were randomized to having a trained CPR Coach vs. no CPR Coach. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. All teams utilized CPR feedback technology. We report the proportion of overall excellent CPR, proportion of chest compressions (CC) with depth 50-60 mm, the proportion of CC with rate 100-120 per minute, CC fraction, and pre-, post-, and peri-shock pause duration. RESULTS CPR coached teams compared with teams without a CPR Coach resulted in an absolute improvements in overall excellent CPR by 31.8% (95% CI, 17.7, 35.9; p < 0.001), mean CC depth compliance by 31.5% (15.7, 47.4; p < 0.001), mean CC depth by 4.6 mm (1.6, 7.5; p < 0.001), mean CC fraction by 5.4% (0.2, 10.6; p = 0.04), and mean pre-, post- and peri-shock pause duration by -2.7 s (-5.1, -0.4; p = 0.02), -1.0 s (-1.8, -0.2; p = 0.01); and -3.8 (-6.6, -1.0; p = 0.008), respectively. Changes in mean CC rate compliance and mean CC rate were not statistically significant. CONCLUSIONS In the presence of CPR feedback technology, the integration of a trained CPR coach into resuscitation teams enhances CPRquality metrics associated with improved survival outcomes from pediatric cardiac arrest.
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Affiliation(s)
- Adam Cheng
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, KidSIM-ASPIRE Research Program, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta, T3B 6A8, Canada.
| | - Jonathan P Duff
- Stollery Children's Hospital, University of Alberta, Canada.
| | - David Kessler
- Columbia University College of Physicians and Surgeons, United States.
| | - Nancy M Tofil
- Children's of Alabama, University of Alabama at Birmingham, United States.
| | - Jennifer Davidson
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Canada.
| | - Yiqun Lin
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Canada.
| | - Jenny Chatfield
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Canada.
| | - Linda L Brown
- Hasbro Children's Hospital, Alpert Medical School of Brown University, United States.
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Bateman LB, White ML, Tofil NM, Clair JM, Needham BL. A Qualitative Examination of Physician Gender and Parental Status in Pediatric End-of-Life Communication. Health Commun 2017; 32:903-909. [PMID: 27436067 DOI: 10.1080/10410236.2016.1196412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In this study we utilized the framework of patient-centered communication to explore the influence of physician gender and physician parental status on (1) physician-parent communication and (2) care of pediatric patients at the end of life (EOL). The findings presented here emerged from a larger qualitative study that explored physician narratives surrounding pediatric EOL communication. The current study includes 17 pediatric critical care and pediatric emergency medicine physician participants who completed narrative interviews between March and October 2012 to discuss how their backgrounds influenced their approaches to pediatric EOL communication. Between April and June of 2013, participants completed a second round of narrative interviews to discuss topics generated out of the first round of interviews. We used grounded theory to inform the design and analysis of the study. Findings indicated that physician gender is related to pediatric EOL communication and care in two primary ways: (1) the level of physician emotional distress and (2) the way physicians perceive the influence of gender on communication. Additionally, parental status emerged as an important theme as it related to EOL decision-making and communication, emotional distress, and empathy. Although physicians reported experiencing more emotional distress related to interacting with patients at the EOL after they became parents, they also felt that they were better able to show empathy to parents of their patients.
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Affiliation(s)
- Lori Brand Bateman
- a Division of Preventive Medicine , University of Alabama at Birmingham School of Medicine
| | - Marjorie Lee White
- b Department of Pediatrics , University of Alabama at Birmingham School of Medicine
| | - Nancy M Tofil
- b Department of Pediatrics , University of Alabama at Birmingham School of Medicine
| | | | - Belinda L Needham
- d Department of Epidemiology , University of Michigan School of Public Health
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Scherzer DJ, Chime NO, Tofil NM, Hamilton MF, Singh K, Stanley RM, Kline J, McNamara LM, Rosen MA, Hunt EA. Survey of pediatric trainee knowledge: dose, concentration, and route of epinephrine. Ann Allergy Asthma Immunol 2017; 118:516-518. [PMID: 28283276 DOI: 10.1016/j.anai.2017.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/09/2017] [Accepted: 01/25/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel J Scherzer
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio.
| | - Nnenna O Chime
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nancy M Tofil
- Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melinda Fiedor Hamilton
- Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rachel M Stanley
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer Kline
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - LeAnn M McNamara
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael A Rosen
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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20
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Johnston EB, King C, Sloane PA, Cox JW, Youngblood AQ, Lynn Zinkan J, Tofil NM. Pediatric anaphylaxis in the operating room for anesthesia residents: a simulation study. Paediatr Anaesth 2017; 27:205-210. [PMID: 27957774 DOI: 10.1111/pan.13052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric intraoperative emergencies are rare but it is crucial for an anesthesia resident to be proficient in their management. Even the more common emergencies like anaphylaxis may not happen frequently for this proficiency to occur. Simulation increases exposure to these rare events in a safe learning environment to improve skills and build confidence while standardizing curriculum. OBJECTIVE Anesthesia residents participated in a simulated case of intraoperative pediatric anaphylaxis to evaluate knowledge and performance gaps. The study also sought to determine whether a difference exists between second- (CA2) and third-year (CA3) anesthesia residents when managing pediatric anaphylaxis and cardiopulmonary arrest. METHODS Anesthesia residents completed a standardized programmed simulation of intraoperative anaphylaxis in a 5-year old undergoing tonsillectomy and adenoidectomy. Anaphylaxis presented and progressed to bradycardia and pulseless electrical activity if anaphylaxis went unnoticed or untreated. Key time points were recorded. A scripted debriefing and written evaluation followed. RESULTS Average time to diagnose anaphylaxis was 7.6 min, and time to give epinephrine was 6.5 min. Thirty-five percent of residents started epinephrine infusion following initial bolus. Average time calling for help between CA3 and CA2 residents was 2.5 min vs 5 min (P = 0.01). CA3 residents verbalized a broader differential, including malignant hyperthermia and pneumothorax. Progression to pulseless electrical activity occurred in 65% of sessions prior to epinephrine being administered. No resident initiated chest compressions for bradycardia. CONCLUSIONS Important performance deficits were seen in senior anesthesia residents during a simulated case of pediatric intraoperative anaphylaxis. Although CA3 performed better, deficits still existed. Anesthesia residents and training programs should partner in developing additional training recognizing anaphylaxis, pulseless electrical activity, and indication for chest compressions in a child.
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Affiliation(s)
- Emily B Johnston
- Department of Anesthesia, Baptist Health Paducah, Paducah, KY, USA
| | - Collin King
- Department of Anesthesia, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter A Sloane
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jerral W Cox
- Department of Anesthesia, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jerry Lynn Zinkan
- Pediatric Simulation Center, Children's of Alabama, Birmingham, AL, USA
| | - Nancy M Tofil
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Prabhakaran P, Sasser WC, Kalra Y, Rutledge C, Tofil NM. Ventilator graphics. Minerva Pediatr 2016; 68:456-469. [PMID: 27471820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Providing optimal mechanical ventilation to critically-ill children remains a challenge. Patient-ventilator dyssynchrony results frequently with numerous deleterious consequences on patient outcome including increased requirement for sedation, prolonged duration of ventilation, and greater imposed work of breathing. Most currently used ventilators have real-time, continuously-displayed graphics of pressure, volume, and flow versus time (scalars) as well as pressure, and flow versus volume (loops). A clear understanding of these graphics provides a lot of information about the mechanics of the respiratory system and the patient ventilator interaction in a dynamic fashion. Using this information will facilitate tailoring the support provided and the manner in which it is provided to best suit the dynamic needs of the patient. This paper starts with a description of the scalars and loops followed by a discussion of the information that can be obtained from each of these graphics. A review will follow, on the common types of dyssynchronous interactions and how each of these can be detected on the ventilator graphics. The final section discusses how graphics can be used to optimize the ventilator support provided to patients.
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Affiliation(s)
- Priya Prabhakaran
- Section of Critical Care, Department of Pediatrics, University of Alabama, Birmingham, AL, USA -
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Cravens MG, Benner K, Beall J, Worthington M, Denson B, Youngblood AQ, Zinkan JL, Tofil NM. Knowledge Gain of Pharmacy Students and Pharmacists Comparing Simulation Versus Traditional Learning Methodology. J Pediatr Pharmacol Ther 2016; 21:476-485. [PMID: 28018149 DOI: 10.5863/1551-6776-21.6.476] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES: The purpose of this study was to evaluate the difference between education via written materials alone and written materials enhanced with hands-on simulation. METHODS: A simulation case, educational module, and assessment regarding torsades de pointes (TdP) in an adolescent patient were designed. The written educational module was given to all study participants. A total of 92 third-year pharmacy students and 26 pharmacists participated in the study. RESULTS: When approximately half of the participants had been to simulation, an anonymous assessment was given. Responses from those who had been to simulation and those who had not, and whether they had read, skimmed or not read the educational material were compared. A non-paired Student t-test compared the percentage correct and responses of individual questions between groups. Mean participant scores of those who went to simulation (70% ± 16%) were statistically significantly higher than mean scores of those who had not attended simulation (54% ± 21%; p<0.0001). Furthermore, those who attended simulation and read the module (72% ± 3%), skimmed (68% ± 13%), or did not read the module (66% ± 16%) had higher scores than those who did not attend simulation and read the module (62% ± 26%), skimmed the module (54 ± 17%) or did not read the module (51% ± 20%). CONCLUSIONS: Hands-on simulation significantly improved assessment scores. Overall, reading the educational module and participating in simulation yielded the best scores. Participants who attended the simulation and did not read the module had higher average scores than participants who read the educational module and did not go to simulation.
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Affiliation(s)
- Mary Grace Cravens
- Children's Hospital of Georgia at Augusta University Medical Center, Augusta, Georgia
| | - Kim Benner
- McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - Jennifer Beall
- McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - Mary Worthington
- McWhorter School of Pharmacy, Samford University, Birmingham, Alabama ; Children's of Alabama, Birmingham, Alabama
| | | | | | | | - Nancy M Tofil
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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Larson-Williams LM, Youngblood AQ, Peterson DT, Zinkan JL, White ML, Abdul-Latif H, Matalka L, Epps SN, Tofil NM. Interprofessional, multiple step simulation course improves pediatric resident and nursing staff management of pediatric patients with diabetic ketoacidosis. World J Crit Care Med 2016; 5:212-218. [PMID: 27896145 PMCID: PMC5109920 DOI: 10.5492/wjccm.v5.i4.212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/15/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the use of a multidisciplinary, longitudinal simulation to educate pediatric residents and nurses on management of pediatric diabetic ketoacidosis.
METHODS A multidisciplinary, multiple step simulation course was developed by faculty and staff using a modified Delphi method from the Pediatric Simulation Center and pediatric endocrinology department. Effectiveness of the simulation for the residents was measured with a pre- and post-test and a reference group not exposed to simulation. A follow up post-test was completed 3-6 mo after the simulation. Nurses completed a survey regarding the education activity.
RESULTS Pediatric and medicine-pediatric residents (n = 20) and pediatric nurses (n = 25) completed the simulation course. Graduating residents (n = 16) were used as reference group. Pretest results were similar in the control and intervention group (74% ± 10% vs 76% ± 15%, P = 0.658). After completing the intervention, participants improved in the immediate post-test in comparison to themselves and the control group (84% ± 12% post study; P < 0.05). The 3-6 mo follow up post-test results demonstrated knowledge decay when compared to their immediate post-test results (78% ± 14%, P = 0.761). Residents and nurses felt the interdisciplinary and longitudinal nature of the simulation helped with learning.
CONCLUSION Results suggest a multidisciplinary, longitudinal simulation improves immediate post-intervention knowledge but important knowledge decay occurs, future studies are needed to determine ways to decrease this decay.
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Bateman LB, Tofil NM, White ML, Dure LS, Clair JM, Needham BL. Physician Communication in Pediatric End-of-Life Care: A Simulation Study. Am J Hosp Palliat Care 2015; 33:935-941. [PMID: 26169522 DOI: 10.1177/1049909115595022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life. METHODS Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent. RESULTS Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely. CONCLUSION Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units. PRACTICE IMPLICATIONS The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.
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Affiliation(s)
- Lori Brand Bateman
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nancy M Tofil
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marjorie Lee White
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leon S Dure
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Belinda L Needham
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Diaz F, Kalra Y, Tofil NM, Prabhakaran P. High frequency oscillatory ventilation in children. What do we know so far? Minerva Pediatr 2015; 67:123-140. [PMID: 25658591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Respiratory failure in children continues to be a common and important indication for admission to intensive care units around the world. Acute respiratory distress syndrome represents the most severe form of respiratory failure in children and results from a variety of pulmonary and extra-pulmonary conditions. Despite important strides in our understanding and improved ventilator strategies of this very heterogeneous disease process, the mortality continues to be fairly high at 33%. High frequency oscillatory ventilation is an alternative form of mechanical ventilation with some attractive features in respect to attempting to improve gas exchange limiting ventilator induced lung injury. The objective of this review is to discuss the principles and the physiology of high frequency oscillatory ventilation, and its role in the management of children with respiratory failure. The adult literature will briefly be reviewed. The main emphasis on this review will be on the use of the "open lung" strategy in conditions that cause a reduction in functional residual capacity. In addition the "low volume" strategy that is useful in the setting of airleaks, such as pneumothorax and pneumomediastinum, will be briefly discussed.
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Affiliation(s)
- F Diaz
- Critical Care Division, Department of Pediatrics, University of Alabama at Birmingham Birmingham, AL, USA -
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Cheng A, Overly F, Kessler D, Nadkarni VM, Lin Y, Doan Q, Duff JP, Tofil NM, Bhanji F, Adler M, Charnovich A, Hunt EA, Brown LL. Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation 2015; 87:44-50. [DOI: 10.1016/j.resuscitation.2014.11.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/11/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
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Cheng A, Brown LL, Duff JP, Davidson J, Overly F, Tofil NM, Peterson DT, White ML, Bhanji F, Bank I, Gottesman R, Adler M, Zhong J, Grant V, Grant DJ, Sudikoff SN, Marohn K, Charnovich A, Hunt EA, Kessler DO, Wong H, Robertson N, Lin Y, Doan Q, Duval-Arnould JM, Nadkarni VM. Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial. JAMA Pediatr 2015; 169:137-44. [PMID: 25531167 DOI: 10.1001/jamapediatrics.2014.2616] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines. OBJECTIVE To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams). INTERVENTIONS Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA. MAIN OUTCOMES AND MEASURES The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA. RESULTS The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation. CONCLUSIONS AND RELEVANCE The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02075450.
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Affiliation(s)
- Adam Cheng
- KidSIM-Assessing Simulation in Pediatrics: Improving Resuscitation Events (ASPIRE) Simulation Research Program, Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Linda L Brown
- Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jonathan P Duff
- Stollery Children's Hospital, University of Alberta, Calgary, Alberta, Canada
| | - Jennifer Davidson
- KidSIM-Assessing Simulation in Pediatrics: Improving Resuscitation Events (ASPIRE) Simulation Research Program, Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Frank Overly
- Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nancy M Tofil
- Children's of Alabama, University of Alabama at Birmingham
| | | | | | - Farhan Bhanji
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Ilana Bank
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Ronald Gottesman
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Mark Adler
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University School of Medicine, Chicago, Illinois
| | - John Zhong
- Children's Medical Center of Dallas, UT Southwestern Medical Center, Dallas, Texas
| | - Vincent Grant
- KidSIM-Assessing Simulation in Pediatrics: Improving Resuscitation Events (ASPIRE) Simulation Research Program, Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - David J Grant
- Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, England
| | | | - Kimberly Marohn
- Baystate Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Alex Charnovich
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A Hunt
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David O Kessler
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hubert Wong
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicola Robertson
- KidSIM-Assessing Simulation in Pediatrics: Improving Resuscitation Events (ASPIRE) Simulation Research Program, Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Yiqun Lin
- KidSIM-Assessing Simulation in Pediatrics: Improving Resuscitation Events (ASPIRE) Simulation Research Program, Section of Emergency Medicine, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Quynh Doan
- British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan M Duval-Arnould
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vinay M Nadkarni
- Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Tofil NM, Dollar J, Zinkan L, Youngblood AQ, Peterson DT, White ML, Stooksberry TN, Jarrell SA, King C. Performance of anesthesia residents during a simulated prone ventricular fibrillation arrest in an anesthetized pediatric patient. Paediatr Anaesth 2014; 24:940-4. [PMID: 24725284 DOI: 10.1111/pan.12406] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exposure to rare pediatric anesthesia emergencies varies depending on the residency program. Simulation can provide increased exposure to these rare events, improve performance of residents, and also aid in standardizing the curriculum. OBJECTIVE The purpose of this study was to evaluate time to recognize and treat ventricular fibrillation in a pediatric prone patient and to expose learners to the difficulties of managing emergencies in prone patients. METHODS Standardized simulation sessions were conducted monthly for 13 months with groups of 1-2 residents in each simulation. The scenario involved a prone patient undergoing posterior spinal fusion. Ventricular fibrillation occurred three minutes into the case. Sessions were viewed by simulation staff, and time to events was recorded. A scripted debriefing followed each case. Evaluations were completed by each participant. RESULTS The average time to start chest compressions was 77 s, and the average time in recognizing ventricular fibrillation was 76 s. No group performed chest compressions while prone. Only one group defibrillated in the prone position. Participants average time to request defibrillation was 108 s. While nine of 13 groups (69%) ordered an arterial blood gas, only five recognized hyperkalemia, and only four groups gave calcium. CONCLUSIONS Anesthesia residents need additional training in recognizing and treating operative ventricular fibrillation, especially in prone patients and rarely encountered etiologies such as hyperkalemia. Training in the treatment of uncommon pediatric emergencies should be a focal point in anesthesia residency programs.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA; Pediatric Simulation Center, Children's of Alabama, Birmingham, AL, USA
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Tofil NM, Peterson DT, Wheeler JT, Youngblood A, Zinkan JL, Lara D, Jakaitis B, Niebauer J, White ML. Repeated versus varied case selection in pediatric resident simulation. J Grad Med Educ 2014; 6:275-9. [PMID: 24949131 PMCID: PMC4054726 DOI: 10.4300/jgme-d-13-00099.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 08/21/2013] [Accepted: 12/10/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Repeated exposure to pediatric emergency scenarios improves technical skills, but it is unclear whether repeated exposure to specific cases affects medical decision making in varied cases. OBJECTIVE We sought to determine whether repeated exposure to 1 scenario would translate to improved performance and decision making in varied scenarios. METHODS Senior pediatrics residents participated in 3 scenarios with scripted debriefing. Residents were randomized to repeated practice (RP) scenarios or mixed (MIX) scenarios. RP residents completed pulseless electrical activity (PEA) with different stems (Case 1, 2, 3). MIX residents completed PEA (Case 1), seizure (Case 2), and ventricular tachycardia (Case 3) scenarios. Four months later, participants returned to complete 3 more cases: PEA (Case 4), seizure (Case 5), and critical coarctation (Case 6). RESULTS Twenty-three residents participated in the study and were randomized to either the RP or the MIX group. The RP group showed statistically significant improvement in time to start chest compressions, whereas the MIX group showed no improvement. Use of a backboard improved significantly in Case 4 for the RP group but not for the MIX group. Similarly, time to check glucose in the seizure scenario was significantly better in the MIX group that had previous exposure to a seizure scenario. No differences in performance were noted between groups in Case 6, which was new to both groups. CONCLUSIONS Results of this study indicate that whereas repeated exposure may improve decision-making skills in similar scenarios, it may not translate to improved medical decision making in other scenarios.
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Tofil NM, Morris JL, Peterson DT, Watts P, Epps C, Harrington KF, Leon K, Pierce C, White ML. Interprofessional simulation training improves knowledge and teamwork in nursing and medical students during internal medicine clerkship. J Hosp Med 2014; 9:189-92. [PMID: 24420579 DOI: 10.1002/jhm.2126] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/04/2013] [Accepted: 11/07/2013] [Indexed: 01/03/2023]
Abstract
Simulation is effective at improving healthcare students' knowledge and communication. Despite increasingly interprofessional approaches to medicine, most studies demonstrate these effects in isolation. We enhanced an existing internal medicine curriculum with immersive interprofessional simulations. For ten months, third-year medical students and senior nursing students were recruited for four, 1-hour simulations. Scenarios included myocardial infarction, pancreatitis/hyperkalemia, upper gastrointestinal bleed, and chronic obstructive pulmonary disease exacerbation. After each scenario, experts in medicine, nursing, simulation, and adult learning facilitated a debriefing. Study measures included pre- and post-tests assessing self-efficacy, communication skills, and understanding of each profession's role. Seventy-two medical students and 30 nursing students participated. Self-efficacy communication scores improved for both (medicine, 18.9 ± 3.3 pretest vs 23.7 ± 3.7 post-test; nursing, 19.6 ± 2.7 pretest vs 24.5 ± 2.5 post-test). Both groups showed improvement in "confidence to correct another healthcare provider in a collaborative manner" (Δ = .97 medicine, Δ = 1.2 nursing). Medical students showed the most improvement in "confidence to close the loop in patient care" (Δ = .93). Nursing students showed the most improvement in "confidence to figure out roles" (Δ = 1.1). This study supports the hypothesis that interdisciplinary simulation improves each discipline's self-efficacy communication skills and understanding of each profession's role. Despite many barriers to interprofessional simulation, this model is being sustained.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Tofil NM, Peterson DT, Harrington KF, Perrin BT, Hughes T, Zinkan JL, Youngblood AQ, Bartolucci A, White ML. A novel iterative-learner simulation model: fellows as teachers. J Grad Med Educ 2014; 6:127-32. [PMID: 24701323 PMCID: PMC3963769 DOI: 10.4300/jgme-d-13-00067.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/29/2013] [Accepted: 07/30/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Simulation is an effective method for teaching clinical skills but has not been widely adopted to educate trainees about how to teach. OBJECTIVE We evaluated a curriculum for pediatrics fellows by using high-fidelity simulation (mannequin with vital signs) to improve pedagogical skills. INTERVENTION The intervention included a lecture on adult learning and active-learning techniques, development of a case from the fellows' subspecialties, and teaching the case to residents and medical students. Teaching was observed by an educator using a standardized checklist. Learners evaluated fellows' teaching by using a structured evaluation tool; learner evaluations and the observer checklist formed the basis for written feedback. Changes in fellows' pedagogic knowledge, attitudes, and self-reported skills were analyzed by using Friedman and Wilcoxon rank-sum test at baseline, immediate postintervention, and 6-month follow-up. RESULTS Forty fellows participated. Fellows' self-ratings significantly improved from baseline to 6-month follow-up for development of learning objectives, effectively reinforcing performance, using teaching techniques to promote critical thinking, providing constructive feedback, and using case studies to teach general rules. Fellows significantly increased agreement with the statement "providing background and context is important" (4.12 to 4.44, P = .02). CONCLUSIONS Simulation was an effective means of educating fellows about teaching, with fellows' attitudes and self-rated confidence improving after participation but returning to baseline at the 6-month assessment. The simulation identified common weaknesses of fellows as teachers, including failure to provide objectives to learners, failure to provide a summary of key learning points, and lack of inclusion of all learners.
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Tofil NM, Rutledge C, Zinkan JL, Youngblood AQ, Stone J, Peterson DT, Slayton D, Makris C, Magruder T, White ML. Ventilator caregiver education through the use of high-fidelity pediatric simulators: a pilot study. Clin Pediatr (Phila) 2013; 52:1038-43. [PMID: 24137039 DOI: 10.1177/0009922813505901] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. Home ventilator programs (HVP) have been developed to train parents of critically ill children. Simulators are used in health care, but not often for parents. We added simulation to our HVP and assessed parents' response. Methods. In July 2008, the HVP at Children's of Alabama added simulation to parent training. Debriefing was provided after the training session to reinforce correct skills and critical thinking. Follow-up surveys were completed after training. Results. Fifteen families participated. All parents were confident in changing tracheostomies, knowing signs of breathing difficulties, and responding to alarms. 71% strongly agree that simulation resulted in feeling better prepared to care for their child. 86% felt simulation improved their confidence in taking care of their child. Conclusion. Simulators provide a crucial transition between learned skills and application. This novel use of simulation-based education improves parents' confidence in emergencies and may lead to shortened training resulting in cost savings.
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Lee White M, Gilbert SR, Youngblood AQ, Zinkan JL, Martin R, Tofil NM. High-fidelity simulations for orthopaedic residents: medical complications and systems challenges. J Bone Joint Surg Am 2013; 95:e70. [PMID: 23677371 DOI: 10.2106/jbjs.l.00761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Marjorie Lee White
- Division of Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South, Birmingham, AL 35233, USA
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Holt RL, Tofil NM, Hurst C, Youngblood AQ, Peterson DT, Zinkan JL, White ML, Clemons JL, Robin NH. Utilizing high-fidelity crucial conversation simulation in genetic counseling training. Am J Med Genet A 2013; 161A:1273-7. [DOI: 10.1002/ajmg.a.35952] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/08/2013] [Indexed: 11/10/2022]
Affiliation(s)
- R. Lynn Holt
- Department of Clinical and Diagnostic Sciences; University of Alabama at Birmingham; Birmingham; Alabama
| | - Nancy M. Tofil
- Department of Pediatrics; University of Alabama at Birmingham; Birmingham; Alabama
| | - Christina Hurst
- Department of Clinical and Diagnostic Sciences; University of Alabama at Birmingham; Birmingham; Alabama
| | | | - Dawn Taylor Peterson
- Department of Pediatrics; University of Alabama at Birmingham; Birmingham; Alabama
| | | | - Marjorie Lee White
- Department of Pediatrics; University of Alabama at Birmingham; Birmingham; Alabama
| | - Jason L. Clemons
- School of Medicine; University of Alabama at Birmingham; Birmingham; Alabama
| | - Nathaniel H. Robin
- Department of Genetics; University of Alabama at Birmingham; Birmingham; Alabama
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Benner KW, Worthington MA, Kimberlin DW, Hill K, Buckley K, Tofil NM. Correlation of vancomycin dosing to serum concentrations in pediatric patients: a retrospective database review. J Pediatr Pharmacol Ther 2012; 14:86-93. [PMID: 23055895 DOI: 10.5863/1551-6776-14.2.86] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Appropriate antimicrobial dosing maximizes therapeutic benefit while minimizing development of antimicrobial resistance. Common pediatric references recommend vancomycin dosing of 40 mg/kg/day divided every 6 to 8 hours for non-central nervous system infections, while some clinicians report utilizing higher initial doses to optimize efficacy. This study compares vancomycin serum concentrations following traditional dosing of 10 mg/kg/dose every 6 to 8 hours versus 15 to 20 mg/kg/dose every 6 to 8 hours. STUDY DESIGN Retrospective database review of vancomycin serum concentrations in pediatric patients. RESULTS Three hundred fifty-seven patients were analyzed. The mean peak concentration of the 10 mg/kg groups every 6 and every 8 hours were below 25 mg/L, whereas the mean peak concentrations of the 15 mg/ kg groups every 6 and 8 hours were within the 25-40 mg/L range (p < 0.001). The mean trough concentration of the 10 mg/kg group every 6 hours was within the 5-15 mg/L range while the 10 mg/kg group dosed every 8 hours was below target. However, the mean trough concentrations of the 15 mg/kg group dosed every 6 and 8 hours were both within the 5-15 mg/L range (p < 0.001). CONCLUSIONS Vancomycin doses of 15 mg/kg every 6 to 8 hours produce peak and trough serum concentrations within target range more often than 10 mg/kg every 6 to 8 hours.
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Affiliation(s)
- Kim W Benner
- Samford University McWhorter School of Pharmacy, Birmingham, Alabama
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Abstract
Health care providers are trained to care for the living. They may complete their education and enter the workforce without ever experiencing the death of a patient. Inexperience with the different roles of the multidisciplinary health care team is common. Moreover, the death of a child has a profound effect on parents and staff. In such situations, the expertise of the multidisciplinary team can make a difference. A multidisciplinary education project that uses high-fidelity simulation based on pediatric death and dying was developed to provide an experience during which health care practitioners could practice communicating with families about the death of their child and dealing with different grief reactions.
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Affiliation(s)
- Amber Q Youngblood
- Pediatric Simulation Center at Children’s of Alabama, 1600 7th Avenue South, Room 306, Birmingham, AL 35233, USA.
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Avis KT, Lozano DJ, White ML, Youngblood AQ, Zinkan L, Niebauer JM, Tofil NM. High-fidelity simulation training for sleep technologists in a pediatric sleep disorders center. J Clin Sleep Med 2012; 8:97-101. [PMID: 22334815 PMCID: PMC3266328 DOI: 10.5664/jcsm.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Severe events of respiratory distress can be life threatening. Although rare in some outpatient settings, effective recognition and management are essential to improving outcomes. The value of high-fidelity simulation has not been assessed for sleep technologists (STs). We hypothesized that knowledge of and comfort level in managing emergent pediatric respiratory events would improve with this innovative method. METHODS We designed a course that utilized high-fidelity human patient simulators (HPS) and that focused on rapid pediatric assessment of young children in the first 5 minutes of an emergency. We assessed knowledge of and comfort with critical emergencies that STs may encounter in a pediatric sleep center utilizing a pre/post-test study design. RESULTS Ten STs enrolled in the study, and scores from the pre- and posttest were compared utilizing a paired samples t-test. Mean participant age was 42 ± 11 years, with average of 9.3 ± 3.3 years of ST experience but minimal experience in managing an actual emergency. Average pretest score was 54% ± 17% correct and improved to 69% ± 16% after the educational intervention (p < 0.05). Participant ratings indicated the course was a well-received, innovative educational methodology. CONCLUSIONS A simulation course focusing on respiratory emergencies requiring basic life support skills during the first 5 min of distress can significantly improve the knowledge of STs. Simulation may provide a highly useful methodology for training STs in the management of rare life-threatening events.
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Affiliation(s)
- Kristin T Avis
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL 35233, USA.
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Niebauer JM, White ML, Zinkan JL, Youngblood AQ, Tofil NM. Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies. Pediatrics 2011; 128:e1195-200. [PMID: 21969287 DOI: 10.1542/peds.2010-3696] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the hypothesis that pediatric resuscitation providers hyperventilate patients via bag-valve-mask (BVM) ventilation during performance of cardiopulmonary resuscitation (CPR), quantify the degree of excessive ventilation provided, and determine if this tendency varies according to provider type. METHODS A retrospective, observational study was conducted of 72 unannounced, monthly simulated pediatric medical emergencies ("mock codes") in a tertiary care, academic pediatric hospital. Responders were code team members, including pediatric residents and interns (MDs), respiratory therapists (RTs), and nurses (RNs). All sessions were video-recorded and reviewed for the rate of BVM ventilation, rate of chest compressions, and the team members performing these tasks. The type of emergency, location of the code, and training level of the team leader were also recorded. RESULTS Hyperventilation was present in every mock code reviewed. The mean rate of BVM ventilation for all providers in all scenarios was 40.6 ± 11.8 breaths per minute (BPM). The mean ventilation rates for RNs, RTs, and MDs were 40.8 ± 14.7, 39.9 ± 11.7, and 40.5 ± 10.3 BPM, respectively, and did not differ among providers (P = .94). All rates were significantly higher than the recommended rate of 8 to 20 BPM (per Pediatric Advanced Life Support guidelines, varies with patient age) (P < .001). The mean ventilation rate in cases of isolated respiratory arrest was 44.0 ± 13.9 BPM and was not different from the mean BVM ventilation rate in cases of cardiopulmonary arrest (38.9 ± 14.4 BPM; P = .689). CONCLUSIONS Hyperventilation occurred in simulated pediatric resuscitation and did not vary according to provider type. Future educational interventions should focus on avoidance of excessive ventilation.
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Affiliation(s)
- Julia M Niebauer
- Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Tofil NM, Benner KW, Zinkan L, Alten J, Varisco BM, White ML. Pediatric intensive care simulation course: a new paradigm in teaching. J Grad Med Educ 2011; 3:81-7. [PMID: 22379527 PMCID: PMC3186272 DOI: 10.4300/jgme-d-10-00070.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 06/16/2010] [Accepted: 10/11/2010] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE True pediatric emergencies are rare. Because resident work hours are restricted and national attention turns toward patient safety, teaching methods to improve physician performance and patient care are vital. We hypothesize that a critical-care simulation course will improve resident confidence and performance in critical-care situations. INTERVENTIONS We developed a monthly pediatric intensive care unit simulation course for second-year pediatric residents that consisted of weekly 1-hour sessions during both of the residents' month-long pediatric intensive care unit rotations. All scenarios used high-fidelity pediatric simulators and immediate videotape-assisted debriefing sessions. In addition, simulated intraosseous line insertion and endotracheal intubations were also performed. RESULTS All residents improved their comfort level and confidence in performing individual key resuscitation tasks. The largest improvements were seen with their perceived ability to intubate children and place intraosseous lines. Both of these skills improved from baseline and compared to third-year-resident controls who had pediatric intensive care unit rotations but no simulations (P = .05 and P = .07, respectively). Videotape reviews showed only 54% ± 12% of skills from a scenario checklist performed correctly. CONCLUSIONS Our simulation-based pediatric intensive care unit training course improves second-year pediatric residents' comfort level but not performance during codes, as well as their perceived intubation and intraosseous ability. Videotape reviews show discordance between objective performance and self-assessment. Further work is necessary to elucidate the reasons for this difference as well as the appropriate role for simulation in the new graduate medical education climate, and to create new teaching modalities to improve resident performance.
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Affiliation(s)
- Nancy M Tofil
- Corresponding author: Nancy M. Tofil, MD, MEd, Department of Pediatrics, 1600 7th Ave, South ACC 504, Birmingham, AL 35233, 205.939.9387,
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Tofil NM, White ML, Grant M, Zinkan JL, Patel B, Jenkins L, Youngblood AQ, Royal SA. Severe contrast reaction emergencies high-fidelity simulation training for radiology residents and technologists in a children's hospital. Acad Radiol 2010; 17:934-40. [PMID: 20471871 DOI: 10.1016/j.acra.2010.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 03/11/2010] [Accepted: 03/18/2010] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES Severe reactions to radiographic contrast agents can be life threatening, and although they are rare, effective recognition and management are essential to improving outcomes. A high-fidelity radiology simulation course for radiology residents and technologists focusing on severe contrast reactions and immediate treatments was designed to test the hypothesis that knowledge would improve with this educational intervention. MATERIALS AND METHODS A prospective pretest and posttest study design was used. Residents and technologists worked in teams of three to five members. Learning objectives focused on demonstrating when and how to use basic life support skills and epinephrine auto-injectors. Each resident and technologist was administered a pretest prior to the start of the case scenarios and a posttest following the debriefing session. Scores from the pretest and posttest for the residents and technologists were compared using a paired-samples t test. RESULTS Nineteen radiology residents and 11 radiology technologists participated. The average test scores were higher and improved significantly following the simulation experience for both the radiology residents (57% vs 82%, P < .001) and technologists (47% vs 72%, P = .006). Anonymous evaluations demonstrated that the experience was well received by residents and technologists, with 97% of learners (29 of 30) rating the experience as extremely or very helpful. Important learning themes included the knowledge of epinephrine auto-injector use and basic life support skills. DISCUSSION High-fidelity simulation for radiology residents and technologists focusing on epinephrine auto-injector use and basic life support skills during the first 5 minutes of a severe contrast reaction can significantly improve recognition and knowledge in treating patients having severe contrast reactions.
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Tofil NM, Benner KW, Worthington MA, Zinkan L, White ML. Use of simulation to enhance learning in a pediatric elective. Am J Pharm Educ 2010; 74:21. [PMID: 20414434 PMCID: PMC2856410 DOI: 10.5688/aj740221] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 08/12/2009] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To assess the impact on learning of adding a pediatric human patient simulation to a pharmacy course. DESIGN Pharmacy students enrolled in a pediatric elective participated in 1 inpatient and 1 outpatient scenario using a pediatric patient simulator. Immediately following each case, reflective debriefing occurred. ASSESSMENT Forty-two students participated in the simulation activity over 2 academic years. A pretest and posttest study design was used, with average scores 4.1 + or - 1.2 out of 9 on pretest and average 7.0 + or - 1.5 out of 9 on posttest (p < 0.0001). Ninety-five percent (40/42) of students' scores improved. Students felt the learning experiences were positive and realistic. CONCLUSIONS Pharmacy students' knowledge and application skills improved through use of pediatric simulation exercises.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, University of Alabama at Birmingham, USA.
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Hayes LW, Oster RA, Tofil NM, Tolwani AJ. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394-400. [DOI: 10.1016/j.jcrc.2008.12.017] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 12/04/2008] [Accepted: 12/23/2008] [Indexed: 10/21/2022]
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Abstract
BACKGROUND Pediatric cardiopulmonary arrests are rare. Mock codes were instituted to bridge the gap between opportunity and reality. AIM The goal was to improve medical caregivers' skills in pediatric resuscitation. METHODS All pediatric and internal medicine/pediatric (med/peds) residents were anonymously surveyed pre- and post-intervention about confidence level about codes and code skills. Twenty mock codes were conducted during the 1 year intervention period. Statistical comparisons were made between each resident pre- and post-survey, graduating third-year residents (PGY3s) prior to intervention versus PGY3s with mock codes and pediatric versus med/peds residents. RESULTS All residents significantly improved in their perception of overall skill level during the study (p < 0.0001). PGY3s were significantly more confident in their skills than PGY2s or PGY1s and PGY2s were significantly more confident than PGY1s both pre- and post-mock codes (p < 0.0001). Med/peds residents were significantly more confident in their skills than pediatric residents both pre- (p = 0.041) and post-intervention (p = 0.016). The two skills with the lowest score post-intervention were the ability to place an interosseous line and the ability to manage cardiac dysrhythmias. CONCLUSIONS Pediatric mock codes can improve resident confidence and self-assessment of their resuscitation skills. Data from surveys such as this can be used to design future skill-based educational initiatives.
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Affiliation(s)
- Nancy M Tofil
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Abstract
OBJECTIVE Our goal was to report our institutional experience with recombinant factor VIIa for the treatment and/or prevention of bleeding in nonhemophiliac children. METHODS This was a retrospective case series in a tertiary pediatric referral hospital. RESULTS During 1999-2006, 135 patients received recombinant factor VIIa for off-label use. The median number of doses was 2; the median dose was 88 mug/kg. The most common diagnoses among patients receiving recombinant factor VIIa were disseminated intravascular coagulation/sepsis (28), surgical bleeding (19), procedural prophylaxis (16), and trauma (15). The median volume of blood products administered 24 hours before recombinant factor VIIa treatment was 29.7 vs 11.7 mL/kg 24 hours after treatment. Only 1 high-risk patient had significant bleeding after receiving prophylactic recombinant factor VIIa before an invasive procedure. Nonsurvivors had significantly increased incidence of multiple organ dysfunction syndrome (75%) compared with survivors (23%). The largest group of patients (n = 28) received recombinant factor VIIa for bleeding and/or coagulopathy because of disseminated intravascular coagulation; the mortality in this group was 26 (93%) of 28. Eleven patients received multiple doses of recombinant factor VIIa to treat bleeding complications after hematopoietic stem cell transplant, without improvement in blood use. Mortality in medical patients was 58% vs 16% in surgical patients. Three patients had significant thrombotic adverse events after receiving recombinant factor VIIa, resulting in 2 deaths and 1 leg amputation. CONCLUSIONS Off-label use of recombinant factor VIIa significantly decreases blood-product administration; surgical patients had control of life-threatening bleeding with low associated mortality. Prophylactic recombinant factor VIIa may be effective in preventing bleeding if given before invasive procedures in children at high risk. Prolonged use of recombinant factor VIIa for bleeding complications after hematopoietic stem cell transplant is not effective in preventing packed red blood cell transfusion. Presence of disseminated intravascular coagulation and mulitorgan dysfunction syndrome may help predict futility of recombinant factor VIIa treatment. Off-label use of recombinant factor VIIa is associated with thromboembolic events in children.
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Affiliation(s)
- Jeffrey A Alten
- University of Alabama at Birmingham, 1600 7th Ave South, ACC 504, Birmingham, AL 35233, USA.
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Shanley TP, Cvijanovich N, Lin R, Allen GL, Thomas NJ, Doctor A, Kalyanaraman M, Tofil NM, Penfil S, Monaco M, Odoms K, Barnes M, Sakthivel B, Aronow BJ, Wong HR. Genome-level longitudinal expression of signaling pathways and gene networks in pediatric septic shock. Mol Med 2007; 13:495-508. [PMID: 17932561 DOI: 10.2119/2007-00065.shanley] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 08/02/2007] [Indexed: 12/18/2022] Open
Abstract
We have conducted longitudinal studies focused on the expression profiles of signaling pathways and gene networks in children with septic shock. Genome-level expression profiles were generated from whole blood-derived RNA of children with septic shock (n=30) corresponding to day one and day three of septic shock, respectively. Based on sequential statistical and expression filters, day one and day three of septic shock were characterized by differential regulation of 2,142 and 2,504 gene probes, respectively, relative to controls (n=15). Venn analysis demonstrated 239 unique genes in the day one dataset, 598 unique genes in the day three dataset, and 1,906 genes common to both datasets. Functional analyses demonstrated time-dependent, differential regulation of genes involved in multiple signaling pathways and gene networks primarily related to immunity and inflammation. Notably, multiple and distinct gene networks involving T cell- and MHC antigen-related biology were persistently downregulated on both day one and day three. Further analyses demonstrated large scale, persistent downregulation of genes corresponding to functional annotations related to zinc homeostasis. These data represent the largest reported cohort of patients with septic shock subjected to longitudinal genome-level expression profiling. The data further advance our genome-level understanding of pediatric septic shock and support novel hypotheses.
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Affiliation(s)
- Thomas P Shanley
- C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, Michigan, USA
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Wong HR, Shanley TP, Sakthivel B, Cvijanovich N, Lin R, Allen GL, Thomas NJ, Doctor A, Kalyanaraman M, Tofil NM, Penfil S, Monaco M, Tagavilla MA, Odoms K, Dunsmore K, Barnes M, Aronow BJ. Genome-level expression profiles in pediatric septic shock indicate a role for altered zinc homeostasis in poor outcome. Physiol Genomics 2007; 30:146-55. [PMID: 17374846 PMCID: PMC2770262 DOI: 10.1152/physiolgenomics.00024.2007] [Citation(s) in RCA: 178] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Human septic shock involves multiple genome-level perturbations. We have conducted microarray analyses in children with septic shock within 24 h of intensive care unit admission, using whole blood-derived RNA. Based on sequential statistical and expression filters, there were 2,482 differentially regulated gene probes (1,081 upregulated and 1,401 downregulated) between patients with septic shock (n = 42) and controls (n = 15). Both gene lists encompassed several biologically relevant gene ontologies and canonical pathways. Notably, many of the genes downregulated in the patients with septic shock, relative to the controls, participate in gene ontologies related to metal or zinc homeostasis. Comparison of septic shock survivors (n = 33) and nonsurvivors (n = 9) demonstrated differential regulation of 63 gene probes. Among the 63 gene probes differentially regulated between septic shock survivors and nonsurvivors, two isoforms of metallothionein (MT) demonstrated increased expression in the nonsurvivors. Consistent with the ability of MT to sequester zinc in the intracellular compartment, nonsurvivors had lower serum zinc levels compared with survivors. In a corroborating study of murine sepsis, MT-null mice demonstrated a survival advantage compared with wild-type mice. These data represent the largest reported cohort of pediatric patients with septic shock that has undergone genome-level expression profiling based on microarray. The data are biologically plausible and demonstrate that genome-level alterations of zinc homeostasis may be prevalent in clinical pediatric septic shock.
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Affiliation(s)
- Hector R Wong
- Cincinnati Children's Hospital Medical Center and Cincinnati Children's Hospital Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Abstract
Herein we present the largest retrospective case-control series of deep sedation in patients with Rett syndrome, including discussion of the unique aspects of Rett syndrome that make these patients at high risk for sedation. Twenty-one patients with Rett syndrome and 21 control patients who received propofol for deep sedation to facilitate lumbar puncture were compared. Patients with Rett syndrome required significantly less propofol than control patients when standardized for weight and the duration of the procedure (P = .004). Seven of the 21 patients with Rett syndrome compared with none of the control patients experienced a serious adverse event, most of which were due to prolonged apnea (P = .004). All adverse events were transient, and all patients returned to their baseline after the procedure was completed. Sedation of patients with Rett syndrome is associated with a relatively high rate of complications and should not be done without appropriate personnel available who recognize the risks of sedating this unique population.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama, Birmingham, AL 35233, USA.
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Abstract
OBJECTIVE To describe the effects of enteral naloxone used to treat opioid-induced constipation in pediatric intensive care patients. DESIGN Retrospective chart review. SETTING Pediatric intensive care unit. PATIENTS Twenty-three patients who received opioid therapy and enteral naloxone in our institution from January 2003 to February 2004 were compared with a randomly sampled control group matched for age, weight, sex, and length of stay who received opioids but had not received enteral naloxone. INTERVENTIONS None. MEASUREMENTS Daily stool output, daily opiate usage, nutrition, adjuvant laxative use, and side effects were assessed. RESULTS Patients stayed an average of 5 days (range, 0-13 days) in the pediatric intensive care unit before enteral administration of naloxone was instituted and received it for an average of 9 consecutive days (range, 3-30 days). Mean stool output for study patients before administration of enteral naloxone was 0.14 +/- 0.38 stools per day, whereas after its initiation it was 1.60 +/- 1.14 stools per day (p < .001). However, two patients developed significant opiate withdrawal symptoms after receiving enteral naloxone. The average stool output for control patients was 0.53 +/- 1.21 stools per day. CONCLUSIONS Enteral naloxone may be effective in increasing stool output in opioid-induced constipation but carries the risk of introducing withdrawal symptoms. Further studies are needed to evaluate this agent for opioid-induced constipation in the intensive care unit.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Herein we present the largest retrospective case-control series of deep sedation in patients with Rett syndrome, including discussion of the unique aspects of Rett syndrome that make these patients at high risk of sedation. Twenty-one patients with Rett syndrome and 21 control patients who received propofol for deep sedation to facilitate lumbar puncture were compared. Patients with Rett syndrome required significantly less propofol than control patients when standardized for weight and the duration of the procedure (P = .004). Seven of the 21 patients with Rett syndrome compared with none of the control patients experienced a serious adverse event, most of which were due to prolonged apnea (P = .004). All adverse events were transient, and all patients returned to their baseline after the procedure was completed. Sedation of patients with Rett syndrome is associated with a relatively high rate of complications and should not be done without appropriate personnel available who recognize the risks of sedating this unique population.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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Abstract
OBJECTIVE To present a case report of a patient with Noonan syndrome who developed life-threatening gastrointestinal bleeding shortly after cardiac surgery that was successfully treated with recombinant factor VIIa. DESIGN Case report. SETTING Pediatric intensive care unit of a children's hospital. PATIENT Ten-month-old with Noonan syndrome and massive gastrointestinal bleeding resulting in severe hypovolemic shock. INTERVENTIONS Recombinant factor VIIa was used in this patient's severe bleeding associated with Noonan syndrome after no other supportive measures were successful. MEASUREMENTS AND MAIN RESULTS Recombinant Factor VIIa significantly decreased the patient's bleeding and allowed his hypovolemic shock to improve. Ultimately, the patient made a complete recovery. CONCLUSIONS Noonan syndrome has a constellation of both cardiac and noncardiac malformations including an increased risk of bleeding, and recombinant factor VIIa is an important agent in the treatment of significant bleeding.
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Affiliation(s)
- Nancy M Tofil
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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