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Pediatric Mock Codes: An Evidence-Informed Focused Pediatric Resuscitation Program
CLINICAL NURSES FORUM
PEDIATRIC MOCK CODES: AN EVIDENCE-INFORMED FOCUSED PEDIATRIC RESUSCITATION PROGRAM Authors: Rebecca A. Moreira, RN, BSN, CPEN, and Lisa M. Tibbetts, MS, RN, PNP, New Bedford, MA Section Editors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, and Kathryn C. Whalen, DNP, MSN, RN, FAHA
ediatric hospital care is becoming increasingly difficult to sustain related to the economics. The option for many hospitals is to significantly reduce pediatric services or to collaborate with tertiary institutions for regionalization of pediatric services. Southcoast Health is an 825-bed, 3-hospital system located on the southeastern coast of Massachusetts. Similar to other community organizations, the health system needed to make a decision regarding pediatric services. As part of its growth into an Accountable Care Organization, Southcoast Health was committed to providing health care services to this population in the community. The goal is to provide safe, quality pediatric care within the local community. In 2010 an evaluation was completed that provided options for the system. One of the options provided was regionalization of pediatric services. The decision to partner with an academic medical center was made to provide a pediatric hospitalist service focused on inpatient pediatrics and a separate pediatric emergency department in the largest of the 3 hospitals. This hospital has approximately 423 beds and an emergency department with approximately 92,000 visits per year. Of the total ED visits, 15,000 are pediatric patients. Additional pediatric resources were also established with this collaboration including a dedicated medical director, advanced practice nursing program director, and clinical nurse educator. An initial gap analysis was completed by both Southcoast Health and its tertiary partner. It was identified, during the assessment, that on the basis of the American Academy of Pediatrics, American College of Emergency
P
Rebecca A. Moreira is Clinical Educator, Pediatrics, Southcoast Hospitals Group, New Bedford, MA. Lisa M. Tibbetts is Director of Pediatrics and Family Centered Care, Southcoast Hospitals Group, New Bedford, MA. For correspondence, write: Rebecca A. Moreira, RN, BSN, CPEN, Pediatrics, Southcoast Hospitals Group, 101 Page St, New Bedford, MA, 0274; E-mail: [email protected]. J Emerg Nurs 2015;41:337-9. Available online 8 May 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.04.011
July 2015
VOLUME 41 • ISSUE 4
Physicians, and Emergency Nurses Association position statements, there were opportunities for improvement in written guidelines for care, availability of age-appropriate equipment, and staff preparedness for pediatric emergencies. 1 The initial approach to address the formation of guidelines for care included the development of a pediatric-specific resuscitation response guideline and a multidisciplinary clinical practice committee. Although the move in health care is to care for pediatric patients in the primary care setting, children continue to use emergency services. Thus, in 1993, the Institute of Medicine recommended that all agencies with jurisdiction over hospitals “require that hospital emergency departments have available and maintain equipment and supplies appropriate for the emergency care of children.” 2 In 2012 there were over 13.1 million ED visits for children aged younger than 18 years in the United States. 3 Parents expect that at any time, day or night, expert clinicians with the correct skills, knowledge, and equipment are available to take care of their children. In reality, many children enter their local emergency department without standard emergency medical services triaging systems or a wellcoordinated decision regarding the needs of the pediatric patient. 4 The 2006 Centers for Disease Control and Prevention National Center for Health Statistics released the first Emergency Pediatric Services and Equipment Supplement survey, conducted in 2002–2003. 3 It showed that emergency departments generally had 85% of recommended supplies but only 7.2% had all recommended pediatric supplies. A supplement to the 2006 National Hospital Ambulatory Medical Care Survey was conducted to assess progress made between 2003 and 2006. 4 This report showed little change in the availability of emergency pediatric supplies over this period. Of note, this survey also reported that 71.2% of emergency departments surveyed had availability of a board-certified emergency medicine medical doctor (MD) whereas only 23% had access to a boardcertified pediatric emergency medicine MD. 3 Also identified in the Southcoast Health gap analysis was that the percentage of American Heart Association Pediatric Advanced Life Support (PALS) certification among nurses (ie, inpatient, emergency department, and
WWW.JENONLINE.ORG
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CLINICAL NURSES FORUM/Moreira and Tibbetts
preoperative) and other health care personnel (eg, respiratory therapy) providing direct care to the pediatric population was low. To address this gap in knowledge and skill, a tiered strategic plan was developed. The first part of the plan was to increase the number of nurses and health care personnel certified in PALS within the organization. Resources from the tertiary center were used to assist in providing PALS course offerings to Southcoast Health staff, with the expectation of increasing the certification rate by 40% from the baseline rate. On completion of this educational blitz, a site-specific PALS program was put into place to continue monthly provider courses. Adult learning theory states that adults learn best when they are able to assimilate new information into an existing cognitive structure. 5 In anticipation of this need, it was determined that reinforcement of the classroom education would be necessary to ensure that nurses and heath care staff maintained competence. Therefore the American Heart Association PALS model of experiential learning theory, in which students develop knowledge and skill through direct experience with simulation and focused reflection, was adopted. 6,7 Research shows the use of simulation as an enhanced method of providing adult learners with educational opportunities. 8 This change led to the development of an on-unit mock code program that would allow nursing and heath care personnel hands-on opportunities to apply evidence-based practice and skills learned in the classroom directly to the clinical setting within the safety of a high-fidelity simulation scenario.
Pediatric Mock Code Program
The pediatric mock code program initially used pediatricspecific case simulations mirroring core case algorithms learned in PALS. 9 A committee of nurses and physicians was established to develop the objectives of the program. The curriculum plan for the program emphasized continued review of the principles of pediatric cardiopulmonary arrest management, the location of pediatric emergency equipment, the contents of the pediatric code cart used in code situations, and the importance of effective communication and role assignment with all members of the code team. The physician and nurse planning team decided that to best serve the staff, pediatric mock codes would be offered monthly. One day out of the month, staff would be able to participate in any of the 6 offerings of the mock code cases either on the inpatient pediatric unit or in the emergency department. Advanced notification to staff for participation was provided through a flyer with the dates and times. Communication with the local unit leadership, such as managers or resource nurses, facilitated implemen-
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tation without significant disruption to the care environment and individual units. The mock code instructor staffing involves, at a minimum, nursing leadership, medical leadership, and a pediatric educator independent of the team responding to the mock code scenario. This ensures a comprehensive objective assessment of skills, processes, knowledge, and communication that should be demonstrated routinely. In addition, ED nursing or physician leadership is present to evaluate staff performance and to assist in the real-time education to ensure that what is discussed is meaningful and relevant to practice. The ED leadership also helps break down any barriers or concerns identified by staff and provides resources to address these issues as needed. The participation of the variety of stakeholders has clearly shown the benefits and rewards of the interprofessional educational experience. Simulation is completed by allowing staff to use equipment, draw up medications, communicate with colleagues throughout the hospital, and apply psychomotor skills on a high-fidelity mannequin. 10 This is a change because, before implementation of this program, staff only talked through emergency scenarios. Staff identified that this previous type of learning was ineffective. One discovery during the debriefing sessions was that the participants lacked confidence and had a sense of inadequacy with essential skill performance. The ability to practice psychomotor skills during the mock codes was a new and welcomed experience. These feelings were addressed by the educator and leadership by explaining to staff that simulation supports a nonthreatening learning environment that allows participants to demonstrate and explore their own practice and receive positive feedback and the opportunity for improvement.
Assessment of Outcomes of Pediatric Mock Codes EDUCATION ACTIVITIES
One finding of the mock code program was that although staff could perform the skills, the theory and understanding behind their skills were lacking. For example, although staff could articulate the PALS algorithm for lower airway obstruction, their basic understanding of pathophysiology regarding an asthma exacerbation was lacking. Supplemental education was targeted to address these concepts and critical-thinking skills. Another area for improvement from the assessment was inconsistency across units and across all 3 hospitals regarding equipment and approaches to resuscitation care. This led to the implementation of standardization of all
VOLUME 41 • ISSUE 4
July 2015
Moreira and Tibbetts/CLINICAL NURSES FORUM
pediatric equipment across the health system. Expectations for learning and participation were determined. Expectations for staff attendance were established by department leaders for their staff. Subsequently, PALS certification in the emergency department rose from 38% to 47% and continues to progressively increase. Moreover, the respiratory therapists’ PALS certification rose from 25% to 59%. There was 100% certification achieved on the inpatient unit.
Acknowledgment
We thank the staff and leadership who participated in the mock code programs across Southcoast Hospitals Group in an effort to continue to provide quality care for children in our community. We also thank the following individuals: Andrew Harding, RN, Associate Chief Nursing Officer at Charlton Memorial Hospital, and Brian Sard, MD, Medical Director, and Athena Xifaras, MD, Associate Medical Director for Pediatrics at Southcoast Health System.
OUTCOME MEASUREMENT
REFERENCES
During the simulation scenario, 3 specific areas were prioritized for assessment. These included not only elements used for pediatric resuscitation but also other low-volume high-acuity events. Items assessed and tracked for quality improvement included the percentage of completed closed-loop communication for events, the ability for staff to assign roles immediately on entering the scenario, and the ability to follow sequential steps in approaching care. NEXT STEPS
We continue to move the pediatric mock code program and resuscitation education to other areas in which children receive care within the hospital, including radiology, perioperative services, and outpatient areas. As we strive for interprofessional continuity, our current plan is to expand our core team to include a respiratory therapy leader and his or her clinical staff.
1. American Academy of Pediatrics, American College of Emergency Physicians, Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243. 2. Dutch J, Lohr KN, eds. Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993. 3. National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs, Hyattsville, MD: National Center for Health Statistics; 2014. 4. Schappert SM, Bhuiya F. National Health Statistics Reports. Availability of Pediatric Services and Equipment in Emergency Departments: Unites States, 2006, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012. 5. Baumgartner LM. An update on transformational learning. New Dir Adult Contin Educ. 2001;2001(89):15-24. 6. Emergency Nurses Association. Emergency Nursing: Scope and Standards of Practice, Silver Springs, MD: Emergency Nurses Association; 2011. 7. Harding AD, Walker-Cillo G, Duke A, Campos G, Stapleton S. A framework for creating and evaluating competencies for emergency nurses. J Emerg Nurs. 2013;39(3):252-264. 8. Wolf L, Dion K, Lamoureaux E, et al. Using simulated clinical scenarios to evaluate student performance. Nurse Educ. 2011;36(3):128-134.
Conclusion
Patients and their families expect high-quality care. Increasingly, parents and patients use publicly available quality data and anecdotal feedback to draw comparisons between physician practices and hospitals. Using the pediatric mock code team has helped to improve the team’s awareness about resuscitation quality for pediatric patients. Establishing a pediatric mock code and resuscitation program has allowed for interdisciplinary team building; improved the hospital resuscitation response system; and improved practitioners’ skills, knowledge, and confidence to meet the needs of pediatric patients.
July 2015
VOLUME 41 • ISSUE 4
9. Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2010;126(5):e1361-e1399. 10. Hoadley TA. Learning advanced cardiac life support: a comparison study of the effects of low- and high-fidelity simulation. Nurs Educ Perspect. 2009;30(2):91-95.
Submissions to this column are encouraged and may be sent to Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN [email protected] or Kathryn C. Whalen, DNP, MSN, RN, FAHA [email protected]
WWW.JENONLINE.ORG
339
PEDIATRIC MOCK CODES: AN EVIDENCE-INFORMED FOCUSED PEDIATRIC RESUSCITATION PROGRAM Authors: Rebecca A. Moreira, RN, BSN, CPEN, and Lisa M. Tibbetts, MS, RN, PNP, New Bedford, MA Section Editors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, and Kathryn C. Whalen, DNP, MSN, RN, FAHA
ediatric hospital care is becoming increasingly difficult to sustain related to the economics. The option for many hospitals is to significantly reduce pediatric services or to collaborate with tertiary institutions for regionalization of pediatric services. Southcoast Health is an 825-bed, 3-hospital system located on the southeastern coast of Massachusetts. Similar to other community organizations, the health system needed to make a decision regarding pediatric services. As part of its growth into an Accountable Care Organization, Southcoast Health was committed to providing health care services to this population in the community. The goal is to provide safe, quality pediatric care within the local community. In 2010 an evaluation was completed that provided options for the system. One of the options provided was regionalization of pediatric services. The decision to partner with an academic medical center was made to provide a pediatric hospitalist service focused on inpatient pediatrics and a separate pediatric emergency department in the largest of the 3 hospitals. This hospital has approximately 423 beds and an emergency department with approximately 92,000 visits per year. Of the total ED visits, 15,000 are pediatric patients. Additional pediatric resources were also established with this collaboration including a dedicated medical director, advanced practice nursing program director, and clinical nurse educator. An initial gap analysis was completed by both Southcoast Health and its tertiary partner. It was identified, during the assessment, that on the basis of the American Academy of Pediatrics, American College of Emergency
P
Rebecca A. Moreira is Clinical Educator, Pediatrics, Southcoast Hospitals Group, New Bedford, MA. Lisa M. Tibbetts is Director of Pediatrics and Family Centered Care, Southcoast Hospitals Group, New Bedford, MA. For correspondence, write: Rebecca A. Moreira, RN, BSN, CPEN, Pediatrics, Southcoast Hospitals Group, 101 Page St, New Bedford, MA, 0274; E-mail: [email protected]. J Emerg Nurs 2015;41:337-9. Available online 8 May 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.04.011
July 2015
VOLUME 41 • ISSUE 4
Physicians, and Emergency Nurses Association position statements, there were opportunities for improvement in written guidelines for care, availability of age-appropriate equipment, and staff preparedness for pediatric emergencies. 1 The initial approach to address the formation of guidelines for care included the development of a pediatric-specific resuscitation response guideline and a multidisciplinary clinical practice committee. Although the move in health care is to care for pediatric patients in the primary care setting, children continue to use emergency services. Thus, in 1993, the Institute of Medicine recommended that all agencies with jurisdiction over hospitals “require that hospital emergency departments have available and maintain equipment and supplies appropriate for the emergency care of children.” 2 In 2012 there were over 13.1 million ED visits for children aged younger than 18 years in the United States. 3 Parents expect that at any time, day or night, expert clinicians with the correct skills, knowledge, and equipment are available to take care of their children. In reality, many children enter their local emergency department without standard emergency medical services triaging systems or a wellcoordinated decision regarding the needs of the pediatric patient. 4 The 2006 Centers for Disease Control and Prevention National Center for Health Statistics released the first Emergency Pediatric Services and Equipment Supplement survey, conducted in 2002–2003. 3 It showed that emergency departments generally had 85% of recommended supplies but only 7.2% had all recommended pediatric supplies. A supplement to the 2006 National Hospital Ambulatory Medical Care Survey was conducted to assess progress made between 2003 and 2006. 4 This report showed little change in the availability of emergency pediatric supplies over this period. Of note, this survey also reported that 71.2% of emergency departments surveyed had availability of a board-certified emergency medicine medical doctor (MD) whereas only 23% had access to a boardcertified pediatric emergency medicine MD. 3 Also identified in the Southcoast Health gap analysis was that the percentage of American Heart Association Pediatric Advanced Life Support (PALS) certification among nurses (ie, inpatient, emergency department, and
WWW.JENONLINE.ORG
337
CLINICAL NURSES FORUM/Moreira and Tibbetts
preoperative) and other health care personnel (eg, respiratory therapy) providing direct care to the pediatric population was low. To address this gap in knowledge and skill, a tiered strategic plan was developed. The first part of the plan was to increase the number of nurses and health care personnel certified in PALS within the organization. Resources from the tertiary center were used to assist in providing PALS course offerings to Southcoast Health staff, with the expectation of increasing the certification rate by 40% from the baseline rate. On completion of this educational blitz, a site-specific PALS program was put into place to continue monthly provider courses. Adult learning theory states that adults learn best when they are able to assimilate new information into an existing cognitive structure. 5 In anticipation of this need, it was determined that reinforcement of the classroom education would be necessary to ensure that nurses and heath care staff maintained competence. Therefore the American Heart Association PALS model of experiential learning theory, in which students develop knowledge and skill through direct experience with simulation and focused reflection, was adopted. 6,7 Research shows the use of simulation as an enhanced method of providing adult learners with educational opportunities. 8 This change led to the development of an on-unit mock code program that would allow nursing and heath care personnel hands-on opportunities to apply evidence-based practice and skills learned in the classroom directly to the clinical setting within the safety of a high-fidelity simulation scenario.
Pediatric Mock Code Program
The pediatric mock code program initially used pediatricspecific case simulations mirroring core case algorithms learned in PALS. 9 A committee of nurses and physicians was established to develop the objectives of the program. The curriculum plan for the program emphasized continued review of the principles of pediatric cardiopulmonary arrest management, the location of pediatric emergency equipment, the contents of the pediatric code cart used in code situations, and the importance of effective communication and role assignment with all members of the code team. The physician and nurse planning team decided that to best serve the staff, pediatric mock codes would be offered monthly. One day out of the month, staff would be able to participate in any of the 6 offerings of the mock code cases either on the inpatient pediatric unit or in the emergency department. Advanced notification to staff for participation was provided through a flyer with the dates and times. Communication with the local unit leadership, such as managers or resource nurses, facilitated implemen-
338
JOURNAL OF EMERGENCY NURSING
tation without significant disruption to the care environment and individual units. The mock code instructor staffing involves, at a minimum, nursing leadership, medical leadership, and a pediatric educator independent of the team responding to the mock code scenario. This ensures a comprehensive objective assessment of skills, processes, knowledge, and communication that should be demonstrated routinely. In addition, ED nursing or physician leadership is present to evaluate staff performance and to assist in the real-time education to ensure that what is discussed is meaningful and relevant to practice. The ED leadership also helps break down any barriers or concerns identified by staff and provides resources to address these issues as needed. The participation of the variety of stakeholders has clearly shown the benefits and rewards of the interprofessional educational experience. Simulation is completed by allowing staff to use equipment, draw up medications, communicate with colleagues throughout the hospital, and apply psychomotor skills on a high-fidelity mannequin. 10 This is a change because, before implementation of this program, staff only talked through emergency scenarios. Staff identified that this previous type of learning was ineffective. One discovery during the debriefing sessions was that the participants lacked confidence and had a sense of inadequacy with essential skill performance. The ability to practice psychomotor skills during the mock codes was a new and welcomed experience. These feelings were addressed by the educator and leadership by explaining to staff that simulation supports a nonthreatening learning environment that allows participants to demonstrate and explore their own practice and receive positive feedback and the opportunity for improvement.
Assessment of Outcomes of Pediatric Mock Codes EDUCATION ACTIVITIES
One finding of the mock code program was that although staff could perform the skills, the theory and understanding behind their skills were lacking. For example, although staff could articulate the PALS algorithm for lower airway obstruction, their basic understanding of pathophysiology regarding an asthma exacerbation was lacking. Supplemental education was targeted to address these concepts and critical-thinking skills. Another area for improvement from the assessment was inconsistency across units and across all 3 hospitals regarding equipment and approaches to resuscitation care. This led to the implementation of standardization of all
VOLUME 41 • ISSUE 4
July 2015
Moreira and Tibbetts/CLINICAL NURSES FORUM
pediatric equipment across the health system. Expectations for learning and participation were determined. Expectations for staff attendance were established by department leaders for their staff. Subsequently, PALS certification in the emergency department rose from 38% to 47% and continues to progressively increase. Moreover, the respiratory therapists’ PALS certification rose from 25% to 59%. There was 100% certification achieved on the inpatient unit.
Acknowledgment
We thank the staff and leadership who participated in the mock code programs across Southcoast Hospitals Group in an effort to continue to provide quality care for children in our community. We also thank the following individuals: Andrew Harding, RN, Associate Chief Nursing Officer at Charlton Memorial Hospital, and Brian Sard, MD, Medical Director, and Athena Xifaras, MD, Associate Medical Director for Pediatrics at Southcoast Health System.
OUTCOME MEASUREMENT
REFERENCES
During the simulation scenario, 3 specific areas were prioritized for assessment. These included not only elements used for pediatric resuscitation but also other low-volume high-acuity events. Items assessed and tracked for quality improvement included the percentage of completed closed-loop communication for events, the ability for staff to assign roles immediately on entering the scenario, and the ability to follow sequential steps in approaching care. NEXT STEPS
We continue to move the pediatric mock code program and resuscitation education to other areas in which children receive care within the hospital, including radiology, perioperative services, and outpatient areas. As we strive for interprofessional continuity, our current plan is to expand our core team to include a respiratory therapy leader and his or her clinical staff.
1. American Academy of Pediatrics, American College of Emergency Physicians, Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243. 2. Dutch J, Lohr KN, eds. Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993. 3. National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs, Hyattsville, MD: National Center for Health Statistics; 2014. 4. Schappert SM, Bhuiya F. National Health Statistics Reports. Availability of Pediatric Services and Equipment in Emergency Departments: Unites States, 2006, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012. 5. Baumgartner LM. An update on transformational learning. New Dir Adult Contin Educ. 2001;2001(89):15-24. 6. Emergency Nurses Association. Emergency Nursing: Scope and Standards of Practice, Silver Springs, MD: Emergency Nurses Association; 2011. 7. Harding AD, Walker-Cillo G, Duke A, Campos G, Stapleton S. A framework for creating and evaluating competencies for emergency nurses. J Emerg Nurs. 2013;39(3):252-264. 8. Wolf L, Dion K, Lamoureaux E, et al. Using simulated clinical scenarios to evaluate student performance. Nurse Educ. 2011;36(3):128-134.
Conclusion
Patients and their families expect high-quality care. Increasingly, parents and patients use publicly available quality data and anecdotal feedback to draw comparisons between physician practices and hospitals. Using the pediatric mock code team has helped to improve the team’s awareness about resuscitation quality for pediatric patients. Establishing a pediatric mock code and resuscitation program has allowed for interdisciplinary team building; improved the hospital resuscitation response system; and improved practitioners’ skills, knowledge, and confidence to meet the needs of pediatric patients.
July 2015
VOLUME 41 • ISSUE 4
9. Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2010;126(5):e1361-e1399. 10. Hoadley TA. Learning advanced cardiac life support: a comparison study of the effects of low- and high-fidelity simulation. Nurs Educ Perspect. 2009;30(2):91-95.
Submissions to this column are encouraged and may be sent to Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN [email protected] or Kathryn C. Whalen, DNP, MSN, RN, FAHA [email protected]
WWW.JENONLINE.ORG
339