To determine which of the 21 general pediatrics &... more To determine which of the 21 general pediatrics 'milestones' sub-competencies are most difficult to assess using traditional methodologies and which are best suited to simulation-based assessment. We surveyed 2 samples: pediatric simulation experts and pediatric program directors. Respondents were asked about current use of simulation for assessment and to select 5 of the 21 pediatric sub-competencies most difficult to assess using traditional methods and the 5 best suited to simulation-based assessment. Spearman Rank correlation was used to determine a correlation between how the 2 samples ranked the sub-competencies. Forty eight percent (29 of 60) simulation experts and 20% (115 of 571) program directors completed the survey. Few respondents reported using simulation for summative assessment. There are clear differences across the pediatric sub-competencies in perceived difficulty of assessment and suitability to simulation-based assessment. The 3 most difficult to assess sub-competencies were "recognize ambiguity', "demonstrate emotional insight " and "identify one's own strengths and deficiencies." The sub-competencies most suitable to assessment using simulation were "interprofessional teamwork", "clinical decision making" and "effective communication." Program directors and simulation experts had high agreement for both questions, difficult to assess (rho 0.76, p<0.001) and suitable to simulation-based assessment (rho 0.94, p<0.001). Several general pediatrics 'milestones' sub-competencies were identified by pediatric simulation experts and pediatric program directors as difficult to assess using current methodologies, and amenable to simulation-based assessment. The pediatric simulation community should target development of simulation-based assessment tools to these areas.
Introduction Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) alg... more Introduction Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions. Hypothesis/Problem To report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision. Medical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined...
Purpose: To explore whether a simulator based just-in-time (JIT) competency assessment can predic... more Purpose: To explore whether a simulator based just-in-time (JIT) competency assessment can predict clinical infant lumbar puncture (LP) success. Methods: This is a planned sub-analysis of data from a multi-institution prospective study of interns at 21 academic centers who were trained in infant LP using simulation based mastery training SBMT and just-in-time (JIT) refreshers and followed to record their clinical success with infant LP. SBMT involves learners practicing until they achieve a minimum passing score. The specific training and time needed to achieve mastery is customized to each learner. Subjects participated in SBMT at the start of intern year. JIT is a brief supervised practice session used to refresh skills to mastery levels immediately prior to clinical performance. Trained supervisors used the Laerdal® Baby Stap bench-top simulator to facilitate SBMT and JIT sessions. JIT refreshers were available all at all times in the ED, NICU PICU and in-patient unit. At the end...
Introduction Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal... more Introduction Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal modality for education and drilling of mass-casualty incident (MCI) triage is not established. Hypothesis/Problem Medical student triage accuracy and time to triage for computer-based simulated victims and live moulaged actors using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) mass-casualty triage tool were compared, anticipating that student performance and experience would be equivalent. The victim scenarios were created from actual trauma records from pediatric high-mechanism trauma presenting to a participating Level 1 trauma center. The student-reported fidelity of the two modalities was also measured. Comparisons were done using nonparametric statistics and regression analysis using generalized estimating equations. Thirty-three students triaged four live patients and seven computerized patients representing a spectrum of minor, immediate, delayed, an...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2015
Poor teamwork and communication during resuscitations are linked to patient safety problems and p... more Poor teamwork and communication during resuscitations are linked to patient safety problems and poorer outcomes. We present a novel simulation-based educational intervention using game cards to introduce challenges in teamwork. This intervention uses sets of game cards that designate roles, limitations, or communication challenges designed to introduce common communication or teamwork problems. Game cards are designed to be applicable for any simulation-based scenario and are independent from patient physiology. In our example, participants were pediatric emergency medicine fellows undergoing simulation training for orientation. We describe the use of card sets in different scenarios with increasing teamwork challenge and difficulty. Both postscenario and summative debriefings were facilitated to allow participants to reflect on their performance and discover ways to apply their strategies to real resuscitations. In this article, we present our experience with the novel use of game cards to modify simulation scenarios to improve communication and teamwork skills.
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: The quality and impact of simulation-based research (SBR) is hi... more ABSTRACT Introduction/Background: The quality and impact of simulation-based research (SBR) is highly variable and only a minority of published SBR is multicenter in nature. The International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE) was formed in 2011 to promote and enhance single and multicenter SBR in pediatrics with the purpose of improving care and outcomes for pediatric patients. Methods: In 2011, two existing pediatric simulation research networks (Examining Pediatric Resuscitation Education using Simulation and Scripting (EXPRESS) and Patient Outcomes in Simulation Education (POISE) networks merged to form INSPIRE. A research consensus conference was held in January 2011 to establish a network mission statement, research themes and short and long-term research goals. A network executive committee consisting of 11 individuals, was formed to oversee network activities. A network website ( www.inspiresim.com), was developed to support ongoing research projects and serve as the backbone for network activities. Biannual network meetings held at international simulation conferences (IMSH and IPSSW) have provided a working venue for new and ongoing projects. By merging the EXPRESS and POISE networks, the new INSPIRE network has been able to enhance collaborative opportunities, expand the breadth of simulation and research expertise in various areas (eg. statistics, human factors, psychology etc) and foster growth of simulation research in various countries around the world. With 110 participating sites (from 14 different countries) and over 400 active members, INSPIRE represents the largest simulation research network in the world. Seven different research themes (Teamwork, Procedural and Psychomotor Skills, Debriefing, Acute Care and Resuscitation, Technology, Human Factors and Patient Safety) were identified from the 2011 consensus conference, with over 30 INSPIRE multicenter research trials ongoing to address questions related to these themes. The multifunctional network website serves as the central hub by: a) accepting applications for new members; b) housing an INSPIRE member and project database; c) matching members to mentors to help facilitate growth of research projects (and expertise); d) matching members to each other (based on expertise and interest) to enable collaboration and networking; e) accepting new INSPIRE project proposals; and f) providing a central venue for projects with file sharing and communications functionality. Collaboration with the Society for Simulation in Healthcare (SSH) and the International Pediatric Simulation Society (IPSS) and infrastructure grant support has allowed for four network meetings in the past twp years. These network meetings, attended by 60-100 people per meeting, have provided INSPIRE members with an update on network activities and an opportunity for members to present new project ideas. New project ideas are submitted online, scientifically reviewed, and selected for presentation via one or two different standardized formats. Principal investigators of projects selected for 'ALERT Presentations' give short, five minute presentations that provide an overview of the background, hypothesis, proposed methodology and project needs. These are followed by three-four hour working groups with interested INSPIRE members to help address project needs, identify potential collaboratorsband define an action plan moving forward. Principal investigators selected for the second format, 'Research Speed Dating', are setup to meet individually with three selected experts in rotating 30 minute blocks. Experts are carefully selected to ensure they have expertise to address the defined needs of the project. INSPIRE network research over the past two years has resulted in 10 publications, 55 abstract presentations and over 2,500 health professionals trained. Future directions will focus on building network infrastructure and securing funds to support network activities. Results: Conclusion: The development of an international simulation research network has facilitated effective collaboration in multicenter research trials, leading to improved knowledge translation and a focused vision for simulation research on an international level. Disclosures: Laerdal Foundation for Acute Medicine, Heart and Stroke Foundation of Canada Royal College of Physicians and Surgeons of Canada SSH Board of Directors rababy foundation my smart health care Laerdal Foundation Grant RBaby Foundation Laerdal Foundation for Acute Care Medicine and Laerdal Medical Corp; Nihon-Kohden Corporation; none none Laerdal Foundation for Acute Care Medicine and Laerdal Medical Corp; Nihon-Kohden Corporation; none none
Simulation-based skill trainings are common; however, optimal instructional designs that improve ... more Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns' infant lumbar puncture (LP) success. This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009-2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010-2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. A total of 436 first infant LPs were an...
Academic medicine : journal of the Association of American Medical Colleges, Jan 15, 2015
Acquisition of competency in procedural skills is a fundamental goal of medical training. In this... more Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to pr...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: Infant lumbar puncture (ILP) is a common procedure that is cons... more ABSTRACT Introduction/Background: Infant lumbar puncture (ILP) is a common procedure that is considered an essential skill for pediatric trainees by the American Board of Pediatrics. Despite this requirement, there is a 66% reported failure rate when trainees perform ILP (Kessler, 2013). Research done by INSPIRE has demonstrated that mastery learning sessions and just-in-time refreshers can improve procedural competency for ILP. However, the decay in ILP skills over time and success rates of senior residents nearing the end of their training is unknown. This study consisted of a survey of upper level residents to explore their experience in performing and supervising ILPs. The primary aim is to measure the first attempt procedural success rates for senior residents performing ILPs in order to evaluate the skill maintenance over time. Methods: A 30 question survey was developed by expert consensus and piloted by pediatric emergency medicine fellows who provided feedback on content and mechanics of the survey via a modified e-Delphi process. The survey queried residents about their experience with ILP during their final year of training including information about their own performance of ILP and their experience supervising the procedure. Additionally, they were asked to provide specific details about their most recent ILP. The data collected for their most recent ILP mirrors what was collected by INSPIRE in prior studies to document intern ILP performance. The data collection tool was distributed via an email with a SurveyMonkeyTM link from site investigators using a standardized communication pattern. IRB approval was obtained at all 10 participating institutions. Data from the resident&#39;s most recent ILP was used to calculate an overall success rate. Procedural success is defined as first needle pass when its RBC cell count was reported as less than or equal to 1000 or if the fluid is described as clear on the first attempt. Results: One hundred ninety eight (86%) out of a possible 241 3rdand 4thyear residents completed the survey. Eight seven percent were pediatric residents, 10% were combined medicine pediatrics and 3% were emergency medicine. Ninety-two percent were PGY3 and 8% were PGY4. Seventy three percent of respondents reported that they participated in ILP training during their intern year. Respondents reported that they supervised a median of 7 LPs during their final year and performed a median of 2. When asked specific questions about their most recent ILP, 68% reported they were not supervised. Overall ILP success rate was 52.94% (95% CI 43.25%, 62.63). When upper level residents were attempting an ILP after another provider had already attempted, the success rate was 24.14% (95% CI 13.13%, 35.15%) which is statistically significantly lower (P&lt;0.001). Conclusion: Upper level pediatric residents had a first attempt success rate of 53% for ILP. Although this is higher than interns, faculty procedure success rates have been reported to be significantly higher. A significant amount of work remains to close this important gap in procedural training. It is our hope that the INSPIRE developed Procedural Skills Training Package including preparation (LEARN), demonstrations (SEE), simulation-based training (PRACTICE), summative assessment on a simulator (PROVE), clinical performance (DO) and continued training and performance (MAINTAIN) can be used to fill this gap. Reference: 1. Kessler et. al. Interns&#39; Success with Clinical Procedures in Infants after Simulated Training. Pediatrics 2013;131;e811. Disclosures: RBaby Foundation rababy foundation my smart health care.
Just-in-time training (JITT) is an educational strategy where training occurs in close temporal p... more Just-in-time training (JITT) is an educational strategy where training occurs in close temporal proximity to a clinical encounter. A multicenter study evaluated the impact of simulation-based JITT on interns&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; infant lumbar puncture (LP) success rates. Concurrent with this multicenter study, we conducted a qualitative evaluation to describe learner perceptions of this modality of skills training. Eleven interns from a single institution participated in a face-to-face semistructured interview exploring their JITT experience. Interviews were audio-recorded and transcribed. Two investigators reviewed the transcripts, assigned codes to the data, and categorized the codes. Categories were modified by 4 emergency physicians. As a means of data triangulation, we performed focus groups at a second institution. Benefits of JITT included review of anatomic landmarks, procedural rehearsal, and an opportunity to ask questions. These perceived benefits improved confidence with infant LP. Deficits of the training included lack of mannequin fidelity and unrealistic context when compared with an actual LP. An unexpected category, which emerged from our analysis, was that of barriers to JITT performance. Barriers included lack of time in a busy clinical setting and various instructor factors. The focus group findings confirmed and elaborated the benefits and deficits of JITT and the barriers to JITT performance. Just-in-time training improved procedural confidence with infant LP, but work place busyness and instructor lack of support or unawareness were barriers to JITT performance. Optimal LP JITT would occur with improved contextual fidelity. More research is needed to determine optimal training strategies that are effective for the learner and maximize clinical outcomes for the patient.
Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years a... more Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years and older in the United States. This review discusses common injuries in children after motor vehicle trauma and examines the evidence regarding the evaluation and treatment of pediatric patients involved in motor vehicle crashes. Both prehospital and emergency department care are discussed along with a differential diagnosis of the injuries most commonly seen in motor vehicle crashes. The various options for imaging modalities are also discussed in this review. A critical appraisal of the existing guidelines for the management of motor vehicle trauma and for the use of appropriate child-safety restraints is presented. Emergency clinicians will be able to use the patient's history and physical examination findings along with knowledge of common injuries to determine the most appropriate workup and treatment of pediatric patients who present with motor vehicle trauma.
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: Competency-based education (CBE) is a new paradigm for residenc... more ABSTRACT Introduction/Background: Competency-based education (CBE) is a new paradigm for residency training. The International Network for Simulation-Based Pediatric Innovation, Research and Education (INSPIRE) designed and implemented a simulation-based training and assessment program to teach infant lumbar punctures (LPs). This educational model consisted of individualized mastery training during intern orientation and pre-performance just-in-time training (JITT) and competency assessments (CAs) to determine procedural readiness. We aimed to explore barriers and strategies for successful program implementation across several centers in the network. Methods: We conducted a qualitative study of semi-structured interviews and focus groups (1/2013-7/2013) of site directors participating in the INSPIRE LP project using convenience sampling. Using a validated theoretical framework,1,2 we developed an interview guide. Questions were iteratively revised during the interview process for comprehensive understanding. Interviews were audio-recorded and transcribed verbatim. We inductively analyzed the transcripts using grounded theory and applied serial immersion and crystallization cycles to identify and verify emergent themes and subthemes until thematic saturation was achieved. Results: Thematic saturation was attained after interviewing 19 (54%) site directors in 12 one-on-one and 3 group sessions. Collectively, directors identified &gt;75 barriers, voicing four main barriers as most significant: vision and buy-in, education vs. patient care, teaching paradigms and communication. In many institutions, competing visions between site directors and residency directors prevented programmatic buy-in. Some site directors found that with already limited opportunities to perform LPs, residency directors refused to deny interns clinical LPs even after failed CAs. Many believed the ACGME&#39;s mandate for CBE was a powerful motivator and provided guidance to residency directors regarding the LP CA model. Successful site directors strategized to align their project vision with the residency directors&#39; goals to secure buy-in and resources. Many site directors described the conflict between education and patient care while facilitating LPs in clinical arenas. Some faculty viewed the JITT and CAs as cumbersome and difficult to coordinate with interns. In busy units, supervisors and interns focused on clinical responsibilities were more likely to forget JITTs and CAs. Directors were likely to overcome workflow roadblocks in their own units; however, unfamiliarity of key players and workflow in other units usually became an insurmountable challenge. Strategies to overcome these clinical barriers included collaborating with champions from other units, delegating JITTs and CAs to educationally-minded fellows or chief residents to offset the attending workload and empowering interns to advocate for their education. Several directors discussed faculty resistance to shift their approach of teaching procedures from an apprentice to a simulation-based competency model. The difficulty of failing interns during CAs, coupled with concerns of interns losing clinical opportunities after failing, either led supervisors to pass interns after multiple attempts or prevented support of the educational paradigm. Several directors used INSPIRE data showing increased LP success rates in competent trainees and helped supervisors understand how the simulation model for education can promote quality improvement. Communicating with large groups of supervisors and interns created logistical barriers to disseminate program-related information and reminders. While email communication was common, most directors found the emergence of email fatigue. When email communication failed, personal contact with supervisors was an effective strategy to reinforce accountability and change educational culture. Overall, the ability to overcome barriers was influenced by institutional culture, the level of relational coordination between different stakeholders, and site directors&#39; ingenuity to identify and diversify strategies. Conclusion: Understanding institution-specific barriers of implementing CBE provides a platform for developing effective entrepreneurial strategies in clinical education. The collective experiences of INSPIRE site directors highlighted unique challenges of medical education initiatives and may be instructive to clinician-educators in the continuous development and implementation of this LP or other CBE programs. References: 1. Burke W and Litwin GH. A causal model of organizational performance and change. Journal of management 1992;18(3):523-45. 2. McRoy I and Gibbs P. An institution in change: a private institution in transition. The International Journal of Educational Management 2003;17:147. Disclosures: RBaby Foundation rababy foundation my smart health care.
Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and ... more Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.
Simulation-based medical education (SBME) is used to teach residents. However, few studies have e... more Simulation-based medical education (SBME) is used to teach residents. However, few studies have evaluated its clinical impact. The goal of this study was to evaluate the impact of an SBME session on pediatric interns&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; clinical procedural success. This randomized trial was conducted at 10 academic medical centers. Interns were surveyed on infant lumbar puncture (ILP) and child intravenous line placement (CIV) knowledge and watched audiovisual expert modeling of both procedures. Participants were randomized to SBME mastery learning for ILP or CIV and for 6 succeeding months reported clinical performance for both procedures. ILP success was defined as obtaining a sample on the first attempt with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1000 red blood cells per high-power field or fluid described as clear. CIV success was defined as placement of a functioning catheter on the first try. Each group served as the control group for the procedure for which they did not receive the intervention. Two-hundred interns participated (104 in the ILP group and 96 in the CIV group). Together, they reported 409 procedures. ILP success rates were 34% (31 of 91) for interns who received ILP mastery learning and 34% (25 of 73) for controls (difference: 0.2% [95% confidence interval: -0.1 to 0.1]). The CIV success rate was 54%…
To determine which of the 21 general pediatrics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;... more To determine which of the 21 general pediatrics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;milestones&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; sub-competencies are most difficult to assess using traditional methodologies and which are best suited to simulation-based assessment. We surveyed 2 samples: pediatric simulation experts and pediatric program directors. Respondents were asked about current use of simulation for assessment and to select 5 of the 21 pediatric sub-competencies most difficult to assess using traditional methods and the 5 best suited to simulation-based assessment. Spearman Rank correlation was used to determine a correlation between how the 2 samples ranked the sub-competencies. Forty eight percent (29 of 60) simulation experts and 20% (115 of 571) program directors completed the survey. Few respondents reported using simulation for summative assessment. There are clear differences across the pediatric sub-competencies in perceived difficulty of assessment and suitability to simulation-based assessment. The 3 most difficult to assess sub-competencies were &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;recognize ambiguity&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;demonstrate emotional insight &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;identify one&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s own strengths and deficiencies.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; The sub-competencies most suitable to assessment using simulation were &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;interprofessional teamwork&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;clinical decision making&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;effective communication.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Program directors and simulation experts had high agreement for both questions, difficult to assess (rho 0.76, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) and suitable to simulation-based assessment (rho 0.94, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Several general pediatrics &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;milestones&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; sub-competencies were identified by pediatric simulation experts and pediatric program directors as difficult to assess using current methodologies, and amenable to simulation-based assessment. The pediatric simulation community should target development of simulation-based assessment tools to these areas.
Introduction Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) alg... more Introduction Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions. Hypothesis/Problem To report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision. Medical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined...
Purpose: To explore whether a simulator based just-in-time (JIT) competency assessment can predic... more Purpose: To explore whether a simulator based just-in-time (JIT) competency assessment can predict clinical infant lumbar puncture (LP) success. Methods: This is a planned sub-analysis of data from a multi-institution prospective study of interns at 21 academic centers who were trained in infant LP using simulation based mastery training SBMT and just-in-time (JIT) refreshers and followed to record their clinical success with infant LP. SBMT involves learners practicing until they achieve a minimum passing score. The specific training and time needed to achieve mastery is customized to each learner. Subjects participated in SBMT at the start of intern year. JIT is a brief supervised practice session used to refresh skills to mastery levels immediately prior to clinical performance. Trained supervisors used the Laerdal® Baby Stap bench-top simulator to facilitate SBMT and JIT sessions. JIT refreshers were available all at all times in the ED, NICU PICU and in-patient unit. At the end...
Introduction Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal... more Introduction Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal modality for education and drilling of mass-casualty incident (MCI) triage is not established. Hypothesis/Problem Medical student triage accuracy and time to triage for computer-based simulated victims and live moulaged actors using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) mass-casualty triage tool were compared, anticipating that student performance and experience would be equivalent. The victim scenarios were created from actual trauma records from pediatric high-mechanism trauma presenting to a participating Level 1 trauma center. The student-reported fidelity of the two modalities was also measured. Comparisons were done using nonparametric statistics and regression analysis using generalized estimating equations. Thirty-three students triaged four live patients and seven computerized patients representing a spectrum of minor, immediate, delayed, an...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2015
Poor teamwork and communication during resuscitations are linked to patient safety problems and p... more Poor teamwork and communication during resuscitations are linked to patient safety problems and poorer outcomes. We present a novel simulation-based educational intervention using game cards to introduce challenges in teamwork. This intervention uses sets of game cards that designate roles, limitations, or communication challenges designed to introduce common communication or teamwork problems. Game cards are designed to be applicable for any simulation-based scenario and are independent from patient physiology. In our example, participants were pediatric emergency medicine fellows undergoing simulation training for orientation. We describe the use of card sets in different scenarios with increasing teamwork challenge and difficulty. Both postscenario and summative debriefings were facilitated to allow participants to reflect on their performance and discover ways to apply their strategies to real resuscitations. In this article, we present our experience with the novel use of game cards to modify simulation scenarios to improve communication and teamwork skills.
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: The quality and impact of simulation-based research (SBR) is hi... more ABSTRACT Introduction/Background: The quality and impact of simulation-based research (SBR) is highly variable and only a minority of published SBR is multicenter in nature. The International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE) was formed in 2011 to promote and enhance single and multicenter SBR in pediatrics with the purpose of improving care and outcomes for pediatric patients. Methods: In 2011, two existing pediatric simulation research networks (Examining Pediatric Resuscitation Education using Simulation and Scripting (EXPRESS) and Patient Outcomes in Simulation Education (POISE) networks merged to form INSPIRE. A research consensus conference was held in January 2011 to establish a network mission statement, research themes and short and long-term research goals. A network executive committee consisting of 11 individuals, was formed to oversee network activities. A network website ( www.inspiresim.com), was developed to support ongoing research projects and serve as the backbone for network activities. Biannual network meetings held at international simulation conferences (IMSH and IPSSW) have provided a working venue for new and ongoing projects. By merging the EXPRESS and POISE networks, the new INSPIRE network has been able to enhance collaborative opportunities, expand the breadth of simulation and research expertise in various areas (eg. statistics, human factors, psychology etc) and foster growth of simulation research in various countries around the world. With 110 participating sites (from 14 different countries) and over 400 active members, INSPIRE represents the largest simulation research network in the world. Seven different research themes (Teamwork, Procedural and Psychomotor Skills, Debriefing, Acute Care and Resuscitation, Technology, Human Factors and Patient Safety) were identified from the 2011 consensus conference, with over 30 INSPIRE multicenter research trials ongoing to address questions related to these themes. The multifunctional network website serves as the central hub by: a) accepting applications for new members; b) housing an INSPIRE member and project database; c) matching members to mentors to help facilitate growth of research projects (and expertise); d) matching members to each other (based on expertise and interest) to enable collaboration and networking; e) accepting new INSPIRE project proposals; and f) providing a central venue for projects with file sharing and communications functionality. Collaboration with the Society for Simulation in Healthcare (SSH) and the International Pediatric Simulation Society (IPSS) and infrastructure grant support has allowed for four network meetings in the past twp years. These network meetings, attended by 60-100 people per meeting, have provided INSPIRE members with an update on network activities and an opportunity for members to present new project ideas. New project ideas are submitted online, scientifically reviewed, and selected for presentation via one or two different standardized formats. Principal investigators of projects selected for &#39;ALERT Presentations&#39; give short, five minute presentations that provide an overview of the background, hypothesis, proposed methodology and project needs. These are followed by three-four hour working groups with interested INSPIRE members to help address project needs, identify potential collaboratorsband define an action plan moving forward. Principal investigators selected for the second format, &#39;Research Speed Dating&#39;, are setup to meet individually with three selected experts in rotating 30 minute blocks. Experts are carefully selected to ensure they have expertise to address the defined needs of the project. INSPIRE network research over the past two years has resulted in 10 publications, 55 abstract presentations and over 2,500 health professionals trained. Future directions will focus on building network infrastructure and securing funds to support network activities. Results: Conclusion: The development of an international simulation research network has facilitated effective collaboration in multicenter research trials, leading to improved knowledge translation and a focused vision for simulation research on an international level. Disclosures: Laerdal Foundation for Acute Medicine, Heart and Stroke Foundation of Canada Royal College of Physicians and Surgeons of Canada SSH Board of Directors rababy foundation my smart health care Laerdal Foundation Grant RBaby Foundation Laerdal Foundation for Acute Care Medicine and Laerdal Medical Corp; Nihon-Kohden Corporation; none none Laerdal Foundation for Acute Care Medicine and Laerdal Medical Corp; Nihon-Kohden Corporation; none none
Simulation-based skill trainings are common; however, optimal instructional designs that improve ... more Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns' infant lumbar puncture (LP) success. This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009-2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010-2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. A total of 436 first infant LPs were an...
Academic medicine : journal of the Association of American Medical Colleges, Jan 15, 2015
Acquisition of competency in procedural skills is a fundamental goal of medical training. In this... more Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to pr...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: Infant lumbar puncture (ILP) is a common procedure that is cons... more ABSTRACT Introduction/Background: Infant lumbar puncture (ILP) is a common procedure that is considered an essential skill for pediatric trainees by the American Board of Pediatrics. Despite this requirement, there is a 66% reported failure rate when trainees perform ILP (Kessler, 2013). Research done by INSPIRE has demonstrated that mastery learning sessions and just-in-time refreshers can improve procedural competency for ILP. However, the decay in ILP skills over time and success rates of senior residents nearing the end of their training is unknown. This study consisted of a survey of upper level residents to explore their experience in performing and supervising ILPs. The primary aim is to measure the first attempt procedural success rates for senior residents performing ILPs in order to evaluate the skill maintenance over time. Methods: A 30 question survey was developed by expert consensus and piloted by pediatric emergency medicine fellows who provided feedback on content and mechanics of the survey via a modified e-Delphi process. The survey queried residents about their experience with ILP during their final year of training including information about their own performance of ILP and their experience supervising the procedure. Additionally, they were asked to provide specific details about their most recent ILP. The data collected for their most recent ILP mirrors what was collected by INSPIRE in prior studies to document intern ILP performance. The data collection tool was distributed via an email with a SurveyMonkeyTM link from site investigators using a standardized communication pattern. IRB approval was obtained at all 10 participating institutions. Data from the resident&#39;s most recent ILP was used to calculate an overall success rate. Procedural success is defined as first needle pass when its RBC cell count was reported as less than or equal to 1000 or if the fluid is described as clear on the first attempt. Results: One hundred ninety eight (86%) out of a possible 241 3rdand 4thyear residents completed the survey. Eight seven percent were pediatric residents, 10% were combined medicine pediatrics and 3% were emergency medicine. Ninety-two percent were PGY3 and 8% were PGY4. Seventy three percent of respondents reported that they participated in ILP training during their intern year. Respondents reported that they supervised a median of 7 LPs during their final year and performed a median of 2. When asked specific questions about their most recent ILP, 68% reported they were not supervised. Overall ILP success rate was 52.94% (95% CI 43.25%, 62.63). When upper level residents were attempting an ILP after another provider had already attempted, the success rate was 24.14% (95% CI 13.13%, 35.15%) which is statistically significantly lower (P&lt;0.001). Conclusion: Upper level pediatric residents had a first attempt success rate of 53% for ILP. Although this is higher than interns, faculty procedure success rates have been reported to be significantly higher. A significant amount of work remains to close this important gap in procedural training. It is our hope that the INSPIRE developed Procedural Skills Training Package including preparation (LEARN), demonstrations (SEE), simulation-based training (PRACTICE), summative assessment on a simulator (PROVE), clinical performance (DO) and continued training and performance (MAINTAIN) can be used to fill this gap. Reference: 1. Kessler et. al. Interns&#39; Success with Clinical Procedures in Infants after Simulated Training. Pediatrics 2013;131;e811. Disclosures: RBaby Foundation rababy foundation my smart health care.
Just-in-time training (JITT) is an educational strategy where training occurs in close temporal p... more Just-in-time training (JITT) is an educational strategy where training occurs in close temporal proximity to a clinical encounter. A multicenter study evaluated the impact of simulation-based JITT on interns&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; infant lumbar puncture (LP) success rates. Concurrent with this multicenter study, we conducted a qualitative evaluation to describe learner perceptions of this modality of skills training. Eleven interns from a single institution participated in a face-to-face semistructured interview exploring their JITT experience. Interviews were audio-recorded and transcribed. Two investigators reviewed the transcripts, assigned codes to the data, and categorized the codes. Categories were modified by 4 emergency physicians. As a means of data triangulation, we performed focus groups at a second institution. Benefits of JITT included review of anatomic landmarks, procedural rehearsal, and an opportunity to ask questions. These perceived benefits improved confidence with infant LP. Deficits of the training included lack of mannequin fidelity and unrealistic context when compared with an actual LP. An unexpected category, which emerged from our analysis, was that of barriers to JITT performance. Barriers included lack of time in a busy clinical setting and various instructor factors. The focus group findings confirmed and elaborated the benefits and deficits of JITT and the barriers to JITT performance. Just-in-time training improved procedural confidence with infant LP, but work place busyness and instructor lack of support or unawareness were barriers to JITT performance. Optimal LP JITT would occur with improved contextual fidelity. More research is needed to determine optimal training strategies that are effective for the learner and maximize clinical outcomes for the patient.
Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years a... more Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years and older in the United States. This review discusses common injuries in children after motor vehicle trauma and examines the evidence regarding the evaluation and treatment of pediatric patients involved in motor vehicle crashes. Both prehospital and emergency department care are discussed along with a differential diagnosis of the injuries most commonly seen in motor vehicle crashes. The various options for imaging modalities are also discussed in this review. A critical appraisal of the existing guidelines for the management of motor vehicle trauma and for the use of appropriate child-safety restraints is presented. Emergency clinicians will be able to use the patient's history and physical examination findings along with knowledge of common injuries to determine the most appropriate workup and treatment of pediatric patients who present with motor vehicle trauma.
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2013
ABSTRACT Introduction/Background: Competency-based education (CBE) is a new paradigm for residenc... more ABSTRACT Introduction/Background: Competency-based education (CBE) is a new paradigm for residency training. The International Network for Simulation-Based Pediatric Innovation, Research and Education (INSPIRE) designed and implemented a simulation-based training and assessment program to teach infant lumbar punctures (LPs). This educational model consisted of individualized mastery training during intern orientation and pre-performance just-in-time training (JITT) and competency assessments (CAs) to determine procedural readiness. We aimed to explore barriers and strategies for successful program implementation across several centers in the network. Methods: We conducted a qualitative study of semi-structured interviews and focus groups (1/2013-7/2013) of site directors participating in the INSPIRE LP project using convenience sampling. Using a validated theoretical framework,1,2 we developed an interview guide. Questions were iteratively revised during the interview process for comprehensive understanding. Interviews were audio-recorded and transcribed verbatim. We inductively analyzed the transcripts using grounded theory and applied serial immersion and crystallization cycles to identify and verify emergent themes and subthemes until thematic saturation was achieved. Results: Thematic saturation was attained after interviewing 19 (54%) site directors in 12 one-on-one and 3 group sessions. Collectively, directors identified &gt;75 barriers, voicing four main barriers as most significant: vision and buy-in, education vs. patient care, teaching paradigms and communication. In many institutions, competing visions between site directors and residency directors prevented programmatic buy-in. Some site directors found that with already limited opportunities to perform LPs, residency directors refused to deny interns clinical LPs even after failed CAs. Many believed the ACGME&#39;s mandate for CBE was a powerful motivator and provided guidance to residency directors regarding the LP CA model. Successful site directors strategized to align their project vision with the residency directors&#39; goals to secure buy-in and resources. Many site directors described the conflict between education and patient care while facilitating LPs in clinical arenas. Some faculty viewed the JITT and CAs as cumbersome and difficult to coordinate with interns. In busy units, supervisors and interns focused on clinical responsibilities were more likely to forget JITTs and CAs. Directors were likely to overcome workflow roadblocks in their own units; however, unfamiliarity of key players and workflow in other units usually became an insurmountable challenge. Strategies to overcome these clinical barriers included collaborating with champions from other units, delegating JITTs and CAs to educationally-minded fellows or chief residents to offset the attending workload and empowering interns to advocate for their education. Several directors discussed faculty resistance to shift their approach of teaching procedures from an apprentice to a simulation-based competency model. The difficulty of failing interns during CAs, coupled with concerns of interns losing clinical opportunities after failing, either led supervisors to pass interns after multiple attempts or prevented support of the educational paradigm. Several directors used INSPIRE data showing increased LP success rates in competent trainees and helped supervisors understand how the simulation model for education can promote quality improvement. Communicating with large groups of supervisors and interns created logistical barriers to disseminate program-related information and reminders. While email communication was common, most directors found the emergence of email fatigue. When email communication failed, personal contact with supervisors was an effective strategy to reinforce accountability and change educational culture. Overall, the ability to overcome barriers was influenced by institutional culture, the level of relational coordination between different stakeholders, and site directors&#39; ingenuity to identify and diversify strategies. Conclusion: Understanding institution-specific barriers of implementing CBE provides a platform for developing effective entrepreneurial strategies in clinical education. The collective experiences of INSPIRE site directors highlighted unique challenges of medical education initiatives and may be instructive to clinician-educators in the continuous development and implementation of this LP or other CBE programs. References: 1. Burke W and Litwin GH. A causal model of organizational performance and change. Journal of management 1992;18(3):523-45. 2. McRoy I and Gibbs P. An institution in change: a private institution in transition. The International Journal of Educational Management 2003;17:147. Disclosures: RBaby Foundation rababy foundation my smart health care.
Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and ... more Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.
Simulation-based medical education (SBME) is used to teach residents. However, few studies have e... more Simulation-based medical education (SBME) is used to teach residents. However, few studies have evaluated its clinical impact. The goal of this study was to evaluate the impact of an SBME session on pediatric interns&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; clinical procedural success. This randomized trial was conducted at 10 academic medical centers. Interns were surveyed on infant lumbar puncture (ILP) and child intravenous line placement (CIV) knowledge and watched audiovisual expert modeling of both procedures. Participants were randomized to SBME mastery learning for ILP or CIV and for 6 succeeding months reported clinical performance for both procedures. ILP success was defined as obtaining a sample on the first attempt with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1000 red blood cells per high-power field or fluid described as clear. CIV success was defined as placement of a functioning catheter on the first try. Each group served as the control group for the procedure for which they did not receive the intervention. Two-hundred interns participated (104 in the ILP group and 96 in the CIV group). Together, they reported 409 procedures. ILP success rates were 34% (31 of 91) for interns who received ILP mastery learning and 34% (25 of 73) for controls (difference: 0.2% [95% confidence interval: -0.1 to 0.1]). The CIV success rate was 54%…
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