The Impact of a Displayed Checklist on Simulated Pediatric Trauma Resuscitations

BACKGROUND

Advanced Trauma Life Support resuscitation follows a strict protocolized approach to the initial trauma evaluation. Despite this structure, elements of the primary and secondary assessments can still be omitted. The aim of this study is to determine if a cognitive aid checklist reduces omissions and speeds the time to assessment completion. We additionally investigated if a displayed checklist improved performance further.

METHODS

A series of 131 simulated trauma resuscitations were performed. Teams were randomized to 1 of 3 arms (no checklist, handheld checklist, or displayed). The scenarios were recorded and analyzed to determine time to completion and absolute completion of tasks of the primary and secondary survey. The workload of individual team members was assessed via NASA-TLX.

RESULTS

There was no difference in time to completion of surveys among the 3 arms. In the primary survey, there was a nonsignificant increase in the number of completed tasks with the use of the displayed checklist. In the secondary survey, there was a significant improvement in task completion with the displayed checklists with improved evaluation of the pelvis (P = 0.011), lower extremities (P = 0.048), and covering the patient (P = 0.046). There was a significant improvement in performance in those reported among nurse documenters with use of the displayed checklist.

CONCLUSIONS

Despite a structured approach to trauma resuscitations, omissions still occur. The use of a displayed checklist improves performance and reduces omissions without delaying assessment. Better compliance with Advanced Trauma Life Support protocols may improve patient outcomes.

Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial

IMPORTANCE

Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings.

OBJECTIVE

To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. DESIGN Prospective, randomized, factorial study design.

SETTING

The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing.

PARTICIPANTS

We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups. INTERVENTION Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators.

MAIN OUTCOMES AND MEASURES

Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC).

RESULTS

There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes.

CONCLUSIONS AND RELEVANCE

The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Severe hypokalemia caused by oral and rectal administration of bentonite in a pediatric patient

BACKGROUND

Bentonite is a clay substance that has been used as a homeopathic cathartic. Oral ingestion of bentonite in large quantities has the potential to cause gastrointestinal obstruction and electrolyte abnormalities. We present a case of severe hypokalemia in a pediatric patient who received both oral and rectal administrations of bentonite.

CASE

A 3-year-old girl presented with a chief complaint of vomiting, constipation, lethargy, and weakness over several days. On initial evaluation, the child was mildly dehydrated and had a serum potassium of 0.9 mmol/L. Electrocardiographic findings were also consistent with hypokalemia. Upon further questioning, the parents reported that they had been administering a home remedy, containing colloidal bentonite, both orally and rectally as treatment for persistent constipation. The child received intravenous antibiotics, a normal saline bolus, and multiple boluses of potassium chloride, resulting in eventual normalization of her electrolyte abnormalities.

CONCLUSION

Ingestion of large quantities of clay substances, such as bentonite, can result in gastrointestinal binding of essential electrolytes and possible obstruction. Symptoms and laboratory values often resolve with replacement of electrolytes and cessation of bentonite intake. Although cases of oral ingestion of clay-like substances resulting in electrolyte abnormalities have been reported, there are no previously reported human cases of hypokalemia caused specifically by bentonite administration. This may be due to the unique rectal administration seen in this child, which has not previously been described.