A methodical, constructive, goal-oriented rapid repetition of emergency response simulations has emerged as a dominant strategy for pediatric readiness in the hospital setting, according to a detailed description of one such program at the virtual Pediatric Hospital Medicine.
Rather than a single run-through followed by a lengthy debriefing, which has been a traditional approach, short simulations done rapidly and repeatedly until skills are mastered improve skill development, according to Jeanmarie Schied, MD, of the department of pediatrics, University of Chicago Medicine.
Dr. Jeanmarie Schied
“This method utilizes repetitions to develop muscle memory much like an athlete who ‘practices, practices, practices’ until it becomes second nature,” Dr. Schied explained.
Dr. Schied credited this approach to Elizabeth Hunt, MD, PhD, director of the Johns Hopkins Medicine Simulation Center. The method created by Dr. Hunt is called Rapid Cycle Deliberate Practice (RCDP). At the University of Chicago, where the same principles are being applied, “we have had great success,” Dr. Schied said.
Deficiencies in the traditional approach prompted the change. It has been shown that when experienced residents who have performed multiple simulations are compared to new residents with limited experience or when those certified in Pediatric Advanced Life Support (PAL) are compared to those who are not, they “do not necessarily do better” in the metrics used in simulations to measure competence, according to Dr. Schied.
With the RDCP, learners get multiple chances to master skills.
“Everyone makes mistakes, and letting the participants know this ahead of time puts people at ease,” Dr. Schied said. “People want to know they will have a chance to rewind and do it right.”
In setting up an effective simulation program, the first step is a needs assessment. By first gauging the skill and experience level of those scheduled to participate, Dr. Schied said the program can be tailored to the audience.
The next step is formulating learning objectives. Dr. Schied recommended creating these objectives for the case overall and for each phase of the simulation as it progresses from basic clinical assessments through the specific interventions appropriate for the diagnosis.
Within these objectives there are additional goals. For example, the team should work to administer care within prespecified benchmarks, such as an elapsed time of 60 seconds or less for oxygenation or a time of 180 seconds or less for defibrillation, according to Dr. Schied.
Yet, Dr. Schied suggested that enforcing these goals on initial run-throughs might not be appropriate.
“Let the scenario run longer so you can see the deficits,” Dr. Schied said. If, for example, chest compression is not being done correctly, she recommended interrupting the process to provide immediate and direct feedback. In critiquing the performance, Dr. Schied advised against a critical or punitive tone.
“Inform the learners that they are in a safe environment,” she said. It is essential to identify errors so that they can be corrected on the next run of the practice simulation, but Dr. Schied advised instructors to “be nonjudgmental.” Praise is appropriate when warranted, but she also warned, “don’t sugarcoat” a substandard performance.
During the simulation, team leaders should employ action phrases, meaning that the problem and the action needed are expressed at the same time, according to Dr. Schied. Examples include, “the patient is not breathing, start bagging,” or “there is no pulse, start compression.”
“When the team gets used to these action-linked phrases, studies show that they react in a more timely fashion,” Dr. Schied explained at the event sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
In the study by Dr. Hunt that established the effectiveness of RDCP, 51 pediatric residents who had previously participated in a cardiopulmonary arrest simulation were retested again after being retrained with the RDCP methodology (Resuscitation 2014;85:945-51).
RDCP “was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills,” according to Dr. Hunt, who has published frequently on resuscitation training in pediatrics.
Prior to RDCP, traditional methods produced “little improvement” in resuscitation skills when measured over the course of pediatric residency, according to Dr. Hunt. After RDCP, third-year residents were shown to be “significantly more likely than first-years to defibrillate within 2 minutes,” she reported.
However, there are other strategies to improve retention of skills, according to Dr. Schied. For example, it is important to conduct simulations when the staff can focus. Specifically, Dr. Schied recommended conducting simulations immediately after a staff meeting or before a scheduled shift so that clinical responsibilities will not interfere or divert the learner’s attention. She also recommended conducting key simulations quarterly.
“Studies have shown that knowledge deterioration related to resuscitation begins about 4 months after the last simulation,” she said.
In addition to building the skills of individual participants, Dr. Schied emphasized the importance of also developing effective team dynamics and active communication. In the debriefing that should follow every simulation, she recommended encouraging a discussion of strengths and weaknesses of the team response.
Pediatric emergency simulation scenarios are readily available on multiple sites found on the Internet,” Dr. Schied said. She recommended documenting performance so the data are available for subsequent analysis.
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