- Email: [email protected]
Technology-Enhanced Simulation Training for Pediatric Intubation
Abstract: Performance of endotracheal intubation in the pediatric emergency department is a specialized skill, requiring effort to both attain and maintain competence. Skills training can be approached through the “learn, see, practice, prove, do, maintain” framework. Technology-enhanced simulation should be used to assist this process, providing the opportunity for health care practitioners to practice and refine their skills while minimizing the risks to patient safety. Effective simulationbased training programs must incorporate evidence-based instructional design features. Technology-enhanced simulation shows promise for use in “proving” skills attainment as an assessment tool before performance on real patients. When used along with multicenter quality improvement collaborations and video review of skills, technology-enhanced simulation provides benefits to maintaining individual and systems competency in endotracheal intubation.
TechnologyEnhanced Simulation Training for Pediatric Intubation Beth Emerson, MD*, Michael Shepherd, MD†, Marc Auerbach, MD, MSci*
Keywords: simulation; educational technology; training; process assessment; patient safety; intubation; resuscitation *Department of Pediatrics (Emergency Medicine), Yale University School of Medicine, New Haven, CT; †Children’s Emergency Department, Starship Child Health, Auckland District Health Board, Auckland, New Zealand. Reprint requests and correspondence: Beth Emerson, MD, Department of Pediatrics (Emergency Medicine), Yale University School of Medicine, 100 York St, Suite 1D, New Haven, CT 06511. [email protected] (B. Emerson), [email protected] (M. Shepherd), [email protected] (M. Auerbach) 1522-8401 © 2015 Elsevier Inc. All rights reserved.
A
cute respiratory illnesses are one of the most common causes of morbidity and mortality in infants and children. 1 The treatment of many pediatric airway emergencies requires timely and effective oxygenation and ventilation through noninvasive techniques. Although bag valve mask is an appropriate initial therapeutic intervention in most cases, some patients will require emergent endotracheal intubation (ETI) (trauma, respiratory failure, cardiac arrest). Pediatric airway management involves unique anatomical and functional challenges requiring a specific set of knowledge, skills, and attitudes. This article will focus on ETI, not covering basic airway management such as bag mask ventilation or the approach to the difficult airway or advanced airway techniques. Endotracheal intubation in the emergency department (ED) setting can be a life-saving intervention. However, this specialized skill requires significant time and effort to both attain and maintain. Unfortunately, in pediatric emergency medicine, we face a training paradox related to ETI. Whereas ETI skills development requires intensive training and repeated opportunities for practice, clinical ETI experiences are infrequent and
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 203
204
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
decreasing. Although health care providers are caring for patients with greater clinical complexity and acuity, opportunities to practice ETI skills are decreasing because of increased use of noninvasive ventilation and decreased trainee work hours in critical care environments. 2 In addition, the opportunities are being diluted by an increased diversity of practitioners (nurses, prehospital providers, physicians, physician assistants, nurse practitioners, nurse anesthetists), residency programs (emergency medicine, neonatology, anesthesia, pediatrics, family medicine), and stages of learning (students, interns, residents, fellows, attending physicians). Even in very high volume tertiary care pediatric EDs (PEDs), there are few ETIs performed by individual pediatric emergency medicine providers. 3,4 Recent literature has demonstrated poor ETI success rates by pediatric providers at the trainee and attending level across premier academic medical centers. 5–9 Serious patient harm occurs when this procedure is not performed efficiently and effectively by the provider. Recent reports note that up to 20% of patients undergoing ETI will suffer harm due to provider performance deficiencies. 6,9–14 Suboptimal performance is associated with a range of complications from mild patient deterioration (hypoxemia) to serious adverse events (tracheal injury) and death. 10,15,16 Technology-enhanced simulation (TES) can help ensure safe ETI practices and optimal patient outcomes. Technology-enhanced simulation should be implemented in EDs to augment clinical opportunities for training, assessment, and maintenance. Simulation provides unlimited opportunities to develop, practice, and refine ETI skills while minimizing risks to real patients. Technologyenhanced simulation is effective for individual provider skills training, team training, and systems optimization. It can be used across the spectrum of providers from novice medical students to experienced attending physicians. Technology-enhanced simulation is a form of experiential learning that activates and engages learners and educators in ongoing feedback during skills development. It can also be used to measure or assess competence and monitor provider skills maintenance over time. The purpose of this article is to provide a clinically relevant comprehensive review of TES related to pediatric health care providers’ ETI skills development, maintenance, and assessment. First, we will discuss ETI skills development; then, we will discuss skills assessment and maintenance. After reading this article, you will be able to describe the use of TES in developing, assessing, and maintaining pediatric health care providers’ ETI
skills (technical and nontechnical). In addition, you will be able to describe how to leverage TES at the systems level to improve the safety of ETI in your ED.
TECHNOLOGY-ENHANCED SIMULATION FOR ETI SKILLS TRAINING Simulators are the materials and/or devices that are used to represent the patient or clinical task. A variety of simulators are available for pediatric ETI training as represented in Table 1. Simulator fidelity is the degree of exactness with which something is reproduced. There are various types of fidelity at the level of the simulator (texture, appearance, movement) and the simulation (context, environment, stress). With increasing clinical experience with real procedures, participants have an increased need for higher fidelity. For example, a medical student may benefit from a static bench top simulator, whereas an attending physician may require a more sophisticated device. Other factors to consider when selecting a simulator include cost and durability for repeated use. Simulation is the technique (not the technology) of mirroring and amplifying real-life situations with guided and interactive experiences. In addition to providing skills training, TES can be used to develop participants’ knowledge about the procedure, confidence, and nontechnical skills such as teamwork. Safe, efficient, and effective ETI performance is also dependent on system factors including the availability of functioning equipment. The rare frequency of pediatric ETI in the clinical setting can be addressed through systems drills. In situ simulations 17 involve training in the actual patient care unit using equipment and resources from that unit with actual team members working together in an announced or unannounced drill. There is substantive evidence that health care providers’ participation leads to acquisition of knowledge or skills when measured in repeated simulation. A meta-analysis demonstrated that TES training is associated with improved outcomes across a range of topics if used under the “right conditions.” These conditions involve the use of specific features rooted in evidence-based instructional design and are listed in Table 2. 18 Cheng et al 19 conducted a pediatric specific meta-analysis that noted that TES was associated with large effects in comparison with no intervention across 57 pediatric studies that involved many of these features. A growing body of evidence is beginning to explore how simulation-based performance impacts downstream outcomes of patients. 20,21
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 205
TABLE 1. Technology-enhanced simulation for pediatric ETI. Modality
Features
Computer-driven models
Sources
Physiologic modeling, audible sounds, swelling of tongue or glottis, chest rise, cyanosis, sensing of ventilation, diverse sizes (neonatal, infant, toddler, child, adult) Static bench-top models Anatomically correct, increased durability, synthetic human tissues, 3D printing, difficult anatomy (micrognathia) Animal/human cadavers Realistic structures if human, challenges with rigor mortis/tone Screen based (computer, tablet, phone, 3D animation, potential for haptic haptics), virtual reality interface, distributed practice at home
Cost
Laerdal, Gaumard, CAE Healthcare
$$$-$$$$
Simulab, Syndaver, Trucorp, Laerdal, Simulaids, Armstrong Medical, Nasco
$-$$$
Anatomy labs, meat supply stores
$
AHA PALS, AAP NRP, Anesoft, MySmartHealthcare
$-$$$
Abbreviations: AAP, American Academy of Pediatrics; AHA, American Heart Association; NRP, Neonatal Resuscitation Program; PALS, Pediatric Advanced Life Support.
There are few examples of TES for pediatric ETI in the literature. One such example, a randomized crossover trial of TES by Sudikoff et al, 22 demonstrated improved global competency and reduced numbers of harmful actions by residents after TES. Another study by Cordero et al 23 outlined improvements in neonatal resuscitation skills and team behavior including management and leadership skills after a single session of deliberate practice. A study by Finan et al 24 noted similar improvements in performance in a simulated setting but did not demonstrate that this translated to increased success rates for clinical performance by the participants. A recent study demonstrated that partic-
ipation in TES increased the frequency of residents performing intubations but did not improve success rates nor reduce adverse events on real patients. This raises concerns that TES may increase provider confidence without increasing competence. 25 The paucity of data demonstrating improvements in pediatric ETI outcomes after simulation could be related to the current equipment (eg, limitations of fidelity include no secretions, no blood, no tone) and/or how the simulations are being conducted (eg, adherence to best educational practices). The following section will review some of the “best practices” related to delivering TES interventions
TABLE 2. INSPIRE framework for endotracheal intubation skills training. 27 1. Learn 2. See 3. Practice
4. Prove
5. Do 6. Maintain
Reading, didactic lectures, discussion of endotracheal intubation (ETI) • Knowledge about indications, contraindications, equipment, anatomy, individual steps of procedure Watching an expert perform ETI on a patient or simulator • Videos such as the New England Journal of Medicine Videos in Clinical Medicine 62 Deliberate practice of ETI on a simulator • Repeated opportunities in a single session • Multiple sessions distributed over time and location (requires access to equipment) • Practice is close in time and space to real patient care and integrated with nonsimulation activities Mastery learning of ETI on a simulator • Independent performance of procedure from start to finish to achieve a minimum passing score in the simulated environment (requires valid tools) Performing ETI on a patient • Independent, correct, and safe performance of a procedure in the clinical environment Repeated performance of ETI on simulator or patient with feedback and reflection • Required at designated time periods by employer
Abbreviation: INSPIRE, International Network for Simulation-Based Pediatric Innovation.
206
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
TABLE 3. Six key features of effective TES with examples for ETI. 18,63,64 Mastery learning 65–72
Reflective practice
Feedback
Deliberate practice
Range of difficulty/clinical variation
Customized/individualized learning
Intensive facilitated training sessions that are not limited by time, involving coached practice, feedback, and correction until a predefined level of performance is achieved Opportunity for the learner to evaluate what went well and what needs to be improved when performing the procedure Specific evaluative information provided by the supervisor to learner with guidance for improvement: “You are hitting the teeth when you lift up toward the ceiling, try angling toward where the wall hits the ceiling.” Highly structured practice with specific goal of improving ETI performance that involves a motivated trainee, hard work, and immediate and repeated formative feedback from an expert in the procedure (eg, anesthesia attending) Range in age (eg, neonatal, infant, child), range of difficulty (eg, micrognathia, cleft, secretions), performing in the presence of family Learning tailored to needs, for example, one individual may need more practice on selecting equipment and another may need more guidance on assembling the team
for pediatric ETI training in the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) framework for procedural skills training. The INSPIRE network is a collaborative working to improve the care of acutely ill children using research to advance simulationbased education. 26 Learn, see, practice, prove, do, maintain (LSPPDM) is a 6-step evidence-based pedagogical framework for procedural skills training, performance and maintenance. It is described in Table 2. 27 This framework contrasts with the traditional mantra of “see one, do one, teach one” in pediatric ETI through the use of TES.
All simulation is not equal: how, where, when, and by whom TES is used play a major role in its effectiveness. The application of TES as a tool in using these techniques offers benefits over reliance on real patient practice. Technology-enhanced simulation allows for frequent presentation of a standardized patient scenario and maximizes safety for the learner, educator, and patient. A series of reviews has described the most effective instructional design features for delivering TES and is summarized with examples related to ETI in Table 3 and described below. Mastery learning involves participants receiving clear objectives for expected performance. They then engage in active learning with coached deliberate practice (see below), during which they perform a procedure and receive immediate formative feedback directed at improving their performance toward the level of the predefined standard. This iterative process continues as a cycle of practice, feedback, and correction. Learners are expected to continue training until skill mastery has been achieved (ie, when the minimum passing score is attained), but the time required to reach this standard is variable. This methodology has been proven to improve performance in clinical procedures such as central line placement, dialysis catheter insertion, thoracentesis, advanced cardiac life support performance, and infant lumbar puncture. Ericsson 28 first used the term deliberate practice and proposed a theoretical construct characterized by continuous remodeling of practice methods to improve performance-based skills and attain expert performance. Hunt et al 29 described the approach of rapid-cycle deliberate practice. The principles of this technique include maximizing hands-on opportunities for learners to perform the “right way,” immediately providing expert feedback and solutions around observed problems, and fostering an environment of “psychological safety” in which the learner may practice.
TECHNOLOGY-ENHANCED SIMULATION TO EVALUATE COMPETENCY The use of TES for ETI competency assessment is attractive, as the infrequency of patient ETI in the ED environment makes clinical competency assessment difficult. In addition, the use of TES for competency assessment allows trainees to “prove” that they are prepared to safely perform the procedure on a patient. Technology-enhanced simulation has a number of features that potentially make it a suitable tool for the assessment of
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 207
practitioner competency and subsequent credentialing. It can increase the validity of the assessment outcome by replicating the environment and complexity of a real clinical PED setting. It offers an error-tolerant and safe environment to complete assessments, thus providing much greater control over assessment content. It also allows for assessment of more complex core competencies related to intubation, especially those involving dynamic interactions, for example, procedural skills and professionalism. Assessment using TES should be supported by strong validity evidence. Determining the validity of an assessment has been detailed by Standards for Educational and Psychological Testing, 30 with content validity, interrater reliability, internal structure of scoring, external validity, and potential consequences of the assessment process all being important components. Cook et al 31 recently conducted a review of simulation-based assessment of health professionals. Skills assessment for CPR and surgical skills dominated this literature, with few studies systematically reporting validity and few studies reporting a comprehensive validity assessment. 31 There are no published studies describing validated assessment of pediatric ETI skills using TES; however, the existing literature does demonstrate some important principles. Firstly, it is unlikely that TES assessments can provide sufficient validity evidence as an isolated assessment methodology without clinical assessments at a later time. Although few studies have directly compared assessment techniques, Nunnink et al 32 assessed intensive care trainees’ ability to manage a blocked tracheostomy using written, simulation-based, and viva voce (oral) examinations. They demonstrated a low correlation between written examination and viva voce or simulation. 32 A small but important proportion of trainees who passed the written examination committed a number of dangerous errors in simulation, thus suggesting that multimodal assessment is likely to be required. 32 Secondly, when developing scoring systems, a global assessment score is an essential addition to checklist-based scoring, as checklists may not identify fundamentally unsafe or unsatisfactory performance. 33 Thirdly, the assessment is likely to be more discriminatory if it includes qualitative measures of skills achievement and allows for demonstration of a whole procedure. This element of validity has been best demonstrated in TES surgical skills assessment; for example, in the assessment of laparoscopic cholecystectomy, “dissection accuracy” was associated with greater experience and skill, but only the full procedure showed complete discrimination between expert and novice. 34
The INSPIRE group has collated the current skills development checklists for pediatric intubation, and work is ongoing to provide validity evidence. Table 4 outlines necessary components of ETI skills assessment. Khaliq 35 has created an objectively structured assessment of technical skills for ETI that demonstrated strong validity evidence in real patients. Andresen et al 36 reported on an ETI assessment tool for medical students. A recent review by Mills et al 37 reported on a systematic review of procedural assessment instruments for pediatric residents. Nishisaki et al 38,39 have described both a task-based scoring instrument and an assessment tool for team, technical, and behavioral skills during ETI. The only validated procedural checklist for neonatal intubation identified in the literature is for nasotracheal intubation, 40 during which an endotracheal tube is passed through the nares. This is different from orotracheal intubation, during which an endotracheal tube is passed through the oropharynx. Bismilla’s 13-item binary nasotracheal procedural checklist was based upon the Neonatal Resuscitation Program guidelines, and content validity was evaluated using a Delphi process. In addition, a 5-point global rating scale was used, with anchors of 1 to 5 corresponding to poor to excellent performance. Two evaluators scored several intubations, and the interrater reliability was calculated. However, specific information about the validation procedure, including details about the Delphi process, correlation between the checklist and global rating scale, the setting of the validation testing (simulated vs clinical environment), training of the raters on the use of the checklists, or results of the statistical analysis, were not presented in the manuscript. 40
Assessment of More Complex Competencies Intubation competency in the PED can be assessed as a discrete skill or may be assessed in
TABLE 4. Intubation skills assessment components. 27 Key Features of Intubation Skills Assessment • Fidelity of technology: Skills trainer and environment have adequate fidelity to replicate the performance of the task. • Content validity of assessment measures • Global rating scale as part of assessment • Qualitative scoring included Time to achieve intubation Correct length of endotracheal placement
208
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
the broader context of patient management. Simulation has been used to “prove” resident competency across a range of domains, in a range of clinical scenarios. 41–43 This literature demonstrates that scenario-based TES assessment can be developed that will have reliability and validity. Assessment of the airway provider in a team simulation has been described, with a task-based scoring instrument, measuring technical and behavioral elements, demonstrating validity 38 of the instrument. However, valid scenario-based PED intubation competency assessment, including matching the scenario-based TES assessment to clinically observed competency, has not yet been reported. It is recommended that those looking to develop scenario-based TES assessment use published tools. The Simulation Module for Assessment of Resident Targeted Event Responses approach was designed to assist with the development of TES assessment of emergency medicine trainees. 44 It provides a systematic method for creating simulation-based scenarios and measurement tools. It emphasizes the need to link to overall objectives, focus on narrow areas of clinical practice, use multiple assessments (ie, sampling), and be specific about how competency is observed while designing and mapping TES scenarios accordingly. 44 A recent review by Brydges et al 20 reported on the link between TES assessments and patient outcomes. Their team noted 33 studies with 24 involving postgraduates, 8 attending physicians, and 6 medical students. These studies demonstrated a strong correlation between simulation and provider behaviors and a small correlation with patient outcomes. Even more complex competencies are team based. However, there is little definitive evidence base for the use of TES for assessment in this area. A comprehensive methodology has been reported to assist with building simulation-based team assessments— Distinguish, Elaborate, Establish, and Proceduralize 45— however, further research is required to validate the output from such an approach. There is very little evidence about the acceptability of TES assessment to those being assessed. Anecdotal experience suggests that it can be acceptable; however, concerns have been raised about the possibility of simulation-based assessment reducing the safety of TES to the learner as a training modality. In one small study of critical care trainees, simulation-based assessment was acceptable to the trainees. 46 Further study is required in this area, particularly among pediatric emergency trainees and more experienced practitioners. It is crucial that educators and faculty provide clear
expectations to trainees about when TES is being used for training and/or assessments. In summary, the use of TES for assessment in pediatric ETI is attractive but remains unproven despite a rapidly developing evidence base. Assessment is most reliable if more than one assessment modality is used (eg, written examination and TES) and a combination of a checklist and a global score is used. Careful planning is required to identify objectives, develop simulation-based experiences, develop scoring systems, and standardize scenario delivery. Further research is required to determine how to assess more complex team-based competencies around intubation in the PED and to assess the acceptability of TES assessment.
USING TECHNOLOGY AND SIMULATION TO IMPROVE ETI QUALITY AND SAFETY In the busy PED environment, emergent airway procedures constitute an area of potential safety concern. These procedures represent an example of a skill performed at low frequency but with high acuity. Beyond the individual ability to attain the skill set required for successful ETI is the maintenance of these skills and resiliency of the environment to minimize the potential for error in each patient encounter. Using the INSPIRE LSPPDM framework for skills training, the transition from “prove” to “do” and ultimately “maintain” is a challenging one. Maintenance of skill over time in ETI is a challenge to the provider, and studies support decay without practice. 47 Data show an average of 63.7 intubations per PED per year, divided among many providers and learners. Among medical directors surveyed, only 62% feel that this is sufficient for skills maintenance. 48 Cognitive task analysis of the process of intubation as performed by anesthesiologists has demonstrated the occurrence of “task omission” but not “task shedding” of the least important elements. 49 Given the inevitable challenges of maintaining skills over time, risk reduction and quality improvement efforts are increasingly essential.
SKILL MAINTENANCE AND EMERGING TECHNOLOGIES Addition of new technology poses additional strain to maintaining mastery for the provider. Storz video laryngoscopes (Karl Storz, Tuttlingen, Germany) use blades and technique similar to traditional direct laryngoscopy. These show promise
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 209
by improving airway views and increasing success in pediatric operating room and general ED settings. 50–52 This technology allows direct supervision of a learner or assistant by projection of the airway views using video display 53 and the possibility of recording for further review and analysis. Likewise, angulated blade indirect video devices such as GlideScope (Verathon, Bothell, WA) allow excellent visualization but require a slightly different technique than traditional direct laryngoscopy. 52–54 Studies have shown similar performance between this technology and direct laryngoscopy. 52,54,55 In the application of novel airway technology, Behringer and Kristensen 53 described an approach to evaluating its implementation: comparison to standard, expected learning curve, and best method to teach proficiency. This may vary by the type of technology implemented, and techniques including simulation should be considered. Additional cycles of skills learning may be required as new technology is introduced.
MULTICENTER QUALITY COLLABORATIVES Currently, attempts to understand the landscape of pediatric intubation across institutions are under way. Given the relative infrequency of this procedure, multicenter data are essential in both understanding the elements of the pediatric difficult airway as well as implementing improvement efforts. The National Emergency Airway Registry for Kids is a multicenter, research-driven collaborative collecting data surrounding pediatric intubations in the intensive care unit, neonatal intensive care unit, and ED settings. Initial data, including 1516 intubations in the pediatric intensive care unit setting, show that 9% of these airway attempts are categorized as “difficult” and are associated with desaturation or more severe tracheal intubation– associated events at much higher rates. 56 Similarly, this collaboration has allowed for the institution of a risk reduction bundle, including 2 pages of items essential to successful airway attempts. This bundle includes preprocedural risk assessment, team-focused generation of a planned approach, preprocedure time out, and a postprocedure huddle for quality improvement opportunities. 57 Such multicenter quality projects provide the benefit of patient volume and rapid best practice dissemination.
VIDEO AND DATA ACQUISITION FOR QUALITY Relative to individual performance and local quality improvement, one current challenge is the reliance upon self-reported data about compli-
cations and challenges. The procedure of ETI is often very rapid and very complex, making even the medical record a potentially unreliable source of information. Many hospitals are beginning to use video recording of resuscitations, including intubations, which allows for more accurate data collection. Kerrey et al 58 reviewed video recordings of 114 intubations in the PED setting and found 61% associated with adverse events. Significant variation existed between data sources. For example, firstattempt success was noted at 52% by video review, 64% by nursing note, and 58% in the procedure note. In addition, a significantly higher frequency of desaturation was noted by video review (33% vs 19%); and only 1 of 2 patients requiring cardiopulmonary resuscitation during intubation had this noted in the medical record. Of note, interrater reliability of video review was excellent. In a study of video review of intubations in an adult trauma unit, the authors noted that “video allows identification of the precursor events, communications, subtle cues, and fine-grained detail of evidence for the link to outcome that are frequently not available through other sources.” 59 This technique allows institutional efforts in quality improvement to address “work as performed, rather than work as imagined.” A study of emergency medicine residents showed that video was superior to individual recall in adherence to institutional rapid-sequence intubation protocol adherence. Only 61% were correct relative to their use of the Sellick maneuver, and only 80% were correct in their recall of use of end-tidal CO2 monitoring. 60 The uses of these video recordings are manifold. These recordings have been used for individual feedback/education, systematic data capture, and process/environment restructuring. 61 Video review can be used to assess the performance of the individual and the system. Few EDs have used a formal review process surrounding the video capture of airway events, but those that have demonstrate the feasibility of this process.
SUMMARY Achieving sufficient skills attainment and maintenance in ETI performance among PED providers is challenging. Trainees initially learning basic skills, as well as providers attaining advanced skills such as mastery of novel airway technology, can use a structured skills attainment approach such as LSPPDM. Within these learning frameworks, the use of TES allows for experience and demonstration at each stage of the process while ensuring safety of
210
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
real patients. In addition, methods including TES and video review can be easily used in quality improvement efforts, including prospective identification of performance errors at the individual and system level. These techniques comprise a practical, safety-focused approach to integration of learning and quality. Acknowledgments The authors wish to thank Charmin Gohel for formatting and building the reference database and for her assistance with editing and providing thoughtful inputs to the manuscript.
REFERENCES 1. World Health Organization. Child mortality. Available at: http://www.who.int/maternal_child_adolescent/topics/child/ mortality/en/. Accessed 4/13/15. 2. DeMauro SB, Millar D, Kirpalani H. Noninvasive respiratory support for neonates. Curr Opin Pediatr 2014;26:157–62. 3. Guilfoyle FJ, Milner R, Kissoon N. Resuscitation interventions in a tertiary level pediatric emergency department: implications for maintenance of skills. Can J Emerg Med 2011;13:90–5. 4. Mittiga MR, Geis GL, Kerrey BT, et al. The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view. Ann Emerg Med 2013;61:263–70. 5. Haubner LY, Barry JS, Johnston LC, et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation 2013;84: 1359–64. 6. Sanders RC, Giuliano JS, Sullivan JE, et al. Level of trainee and tracheal intubation outcomes. Pediatrics 2013;131: e821–8. 7. Nett S, Emeriaud G, Jarvis JD, et al. Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the National Emergency Airway Registry for Children. Pediatr Crit Care Med 2014;15:306–13. 8. Tarquinio KM, Howell JD, Montgomery V, et al. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med 2015;16:210–8. 9. Nishisaki A, Turner DA, Brown CA, et al. A national emergency airway registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med 2013;41:874–85. 10. Easley RB, Segeleon JE, Haun SE, et al. Prospective study of airway management of children requiring endotracheal intubation before admission to a pediatric intensive care unit. Crit Care Med 2000;28:2058–63. 11. Nishisaki A, Ferry S, Colborn S, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med 2012;13:e5-10. 12. Nishisaki A, Marwaha N, Kasinathan V, et al. Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU. Resuscitation 2011;82:386–90.
13. Gomes Cordeiro AM, Fernandes JC, Troster EJ. Possible risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation. Pediatr Crit Care Med 2004;5:364–8. 14. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002;18:417–23. 15. Chen JJ, Susetio L, Chao CC. Oral complications associated with endotracheal general anesthesia. Ma Zui Xue Za Zhi 1990;28:163–9. 16. Gausche M, Lewis RJ. Out-of-hospital endotracheal intubation of children. JAMA 2000;283:2790–2. 17. Patterson MD, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013;22: 468–77. 18. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306:978–88. 19. Cheng A, Lang TR, Starr SR, et al. Technology-enhanced simulation and pediatric education: a meta-analysis. Pediatrics 2014;133:e1313–23. 20. Brydges R, Hatala R, Zendejas B, et al. Linking simulationbased educational assessments and patient-related outcomes: a systematic review and meta-analysis. Acad Med 2015;90:246–56. 21. Zendejas B, Brydges R, Wang AT, et al. Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med 2013;28:1078–89. 22. Sudikoff SN, Overly FL, Shapiro MJ. High-fidelity medical simulation as a technique to improve pediatric residents' emergency airway management and teamwork: a pilot study. Pediatr Emerg Care 2009;25:651–6. 23. Cordero L, Hart BJ, Hardin R, et al. Deliberate practice improves pediatric residents' skills and team behaviors during simulated neonatal resuscitation. Clin Pediatr (Phila) 2013;52:747–52. 24. Finan E, Bismilla Z, Whyte HE, et al. High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol 2012;32:287–92. 25. Nishisaki A, Donoghue AJ, Colborn S, et al. Effect of just-intime simulation training on tracheal intubation procedure safety in the pediatric intensive care unit. Anesthesiology 2010;113:214–23. 26. INSPIRE. International Network for Simulation-based Pediatric Research, Innovation, & Education. Available at: http:// inspiresim.com. Accessed 4/13/15. 27. Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad Med 2015 [in press]. 28. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med 2008;15: 988–94. 29. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, et al. Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training. Resuscitation 2014;85: 945–51. 30. American Educational Research Association. American Psychological Association, National Council of Measurement in Education. Standards for educational and psychological testing. Washington, DC: AERA; 2014. 31. Cook DA, Brydges R, Zendejas B, et al. Technology-enhanced simulation to assess health professionals: a systematic review
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 211
32.
33.
34. 35.
36. 37.
38.
39.
40.
41. 42. 43.
44.
45. 46.
47.
of validity evidence, research methods, and reporting quality. Acad Med 2013;88:872–83. Nunnink L, Venkatesh B, Krishnan A, et al. A prospective comparison between written examination and either simulation-based or oral viva examination of intensive care trainees' procedural skills. Anaesth Intensive Care 2010;38: 876–82. Hall AK, Pickett W, Dagnone JD. Development and evaluation of a simulation-based resuscitation scenario assessment tool for emergency medicine residents. Can J Emerg Med 2012; 14:139–46. Van Bruwaene S, Schijven MP, Miserez M. Assessment of procedural skills using virtual simulation remains a challenge. J Surg Educ 2014;71:654–61. Khaliq T. Reliability of results produced through objectively structured assessment of technical skills (OSATS) for endotracheal intubation (ETI). J Coll Phys Surg Pak 2013; 23:51–5. Andresen M, Riquelme A, Hasbun P, et al. Evaluation of competencies for tracheal intubation among medical students. Rev Med Chil 2011;139:165–70. Mills DM, Williams DC, Dobson JV. Simulation training as a mechanism for procedural and resuscitation education for pediatric residents: a systematic review. Hosp Pediatr 2013; 3:167–76. Nishisaki A, Donoghue AJ, Colborn S, et al. Development of an instrument for a primary airway provider's performance with an ICU multidisciplinary team in pediatric respiratory failure using simulation. Respir Care 2012;57:1121–8. Nishisaki A, Nguyen J, Colborn S, et al. Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit. Pediatr Crit Care Med 2011;12:406–14. Perlman JM, Wyllie J, Kattwinkel J, et al. Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Pediatrics 2010; 126:e1319–44. Blum RH, Boulet JR, Cooper JB, et al. Simulation-based assessment to identify critical gaps in safe anesthesia resident performance. Anesthesiology 2014;120:129–41. Fehr JJ, Boulet JR, Waldrop WB, et al. Simulation-based assessment of pediatric anesthesia skills. Anesthesiology 2011;115:1308–15. Sidi A, Baslanti TO, Gravenstein N, et al. Simulation-based assessment to evaluate cognitive performance in an anesthesiology residency program. J Grad Med Educ 2014;6: 85–92. Rosen MA, Salas E, Silvestri S, et al. A measurement tool for simulation-based training in emergency medicine: the simulation module for assessment of resident targeted event responses (SMARTER) approach. Simul Healthc 2008;3:170–9. Grand JA, Pearce M, Rench TA, et al. Going DEEP: guidelines for building simulation-based team assessments. BMJ Qual Saf 2013;22:436–48. Nunnink L, Foot C, Venkatesh B, et al. High-stakes assessment of the non-technical skills of critical care trainees using simulation: feasibility, acceptability and reliability. Crit Care Resusc 2014;16:6–12. Kovacs G, Bullock G, Ackroyd-Stolarz S, et al. A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Ann Emerg Med 2000;36:301–9.
48. Losek JD, Olson LR, Dobson JV, et al. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care 2008;24:294–9. 49. Mackenzie C, Xiao Y, Horst R. Video task analysis in high performance teams. Cogn Technol Work 2004;6:139–47. 50. Vlatten A, Aucoin S, Litz S, et al. A comparison of the Storz video laryngoscope and standard direct laryngoscopy for intubation in the pediatric airway—a randomized clinical trial. Paediatr Anaesth 2009;19:1102–7. 51. Sakles JC, Mosier JM, Chiu S, et al. Tracheal intubation in the emergency department: a comparison of GlideScope(R) video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med 2012;42:400–5. 52. Karsli C, Der T. Tracheal intubation in older children with severe retro/micrognathia using the GlideScope Cobalt infant video laryngoscope. Paediatr Anaesth 2010;20:577–8. 53. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66:57–64. 54. Redel A, Karademir F, Schlitterlau A, et al. Validation of the GlideScope video laryngoscope in pediatric patients. Paediatr Anaesth 2009;19:667–71. 55. Fonte M, Oulego-Erroz I, Nadkarni L, et al. A randomized comparison of the GlideScope videolaryngoscope to the standard laryngoscopy for intubation by pediatric residents in simulated easy and difficult infant airway scenarios. Pediatr Emerg Care 2011;27:398–402. 56. Graciano AL, Tamburro R, Thompson AE, et al. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med 2014;40:1659–69. 57. Li RP, Xue FS, Wang SY, et al. Comparing performance of video and direct laryngoscopes for intubation during prehospital cardiopulmonary resuscitation. Am J Emerg Med 2014;32:472–3. 58. Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med 2012;60:251–9. 59. Mackenzie CF, Xiao Y, Hu FM, et al. Video as a tool for improving tracheal intubation tasks for emergency medical and trauma care. Ann Emerg Med 2007;50:436–42. 60. Olsen JC, Gurr DE, Hughes M. Video analysis of emergency medicine residents performing rapid-sequence intubations. J Emerg Med 2000;18:469–72. 61. Mackenzie CF, Xiao Y. Video techniques and data compared with observation in emergency trauma care. Qual Saf Health Care 2003;12 (Suppl 2):ii51–7. 62. Kabrhel C, Thomsen TW, Setnik GS, et al. Orotracheal intubation video. NEJM 2007;356:e15. Available at: http:// www.nejm.org/doi/full/10.1056/NEJMvcm063574. Accessed 4/14/15. 63. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28. 64. McGaghie WC, Issenberg SB, Petrusa ER, et al. A critical review of simulation-based medical education research: 2003-2009. Med Educ 2010;44:50–63. 65. Barsuk JH, Cohen ER, Feinglass J, et al. Use of simulationbased education to reduce catheter-related bloodstream infections. Arch Intern Med 2009;169:1420–3. 66. Kessler DO, Auerbach M, Pusic M, et al. A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills. Simul Healthc 2011;6:197–203.
212
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
67. Barsuk JH, McGaghie WC, Cohen ER, et al. Use of simulationbased mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med 2009;4:397–403. 68. Wayne DB, Barsuk JH, O'Leary KJ, et al. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54. 69. Wayne DB, Fudala MJ, Butter J, et al. Comparison of two standard-setting methods for advanced cardiac life support training. Acad Med 2005;80:S63–6.
70. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006;21:251–6. 71. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med 2005;17:210–6. 72. Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a casecontrol study. Chest 2008;133:56–61.
TechnologyEnhanced Simulation Training for Pediatric Intubation Beth Emerson, MD*, Michael Shepherd, MD†, Marc Auerbach, MD, MSci*
Keywords: simulation; educational technology; training; process assessment; patient safety; intubation; resuscitation *Department of Pediatrics (Emergency Medicine), Yale University School of Medicine, New Haven, CT; †Children’s Emergency Department, Starship Child Health, Auckland District Health Board, Auckland, New Zealand. Reprint requests and correspondence: Beth Emerson, MD, Department of Pediatrics (Emergency Medicine), Yale University School of Medicine, 100 York St, Suite 1D, New Haven, CT 06511. [email protected] (B. Emerson), [email protected] (M. Shepherd), [email protected] (M. Auerbach) 1522-8401 © 2015 Elsevier Inc. All rights reserved.
A
cute respiratory illnesses are one of the most common causes of morbidity and mortality in infants and children. 1 The treatment of many pediatric airway emergencies requires timely and effective oxygenation and ventilation through noninvasive techniques. Although bag valve mask is an appropriate initial therapeutic intervention in most cases, some patients will require emergent endotracheal intubation (ETI) (trauma, respiratory failure, cardiac arrest). Pediatric airway management involves unique anatomical and functional challenges requiring a specific set of knowledge, skills, and attitudes. This article will focus on ETI, not covering basic airway management such as bag mask ventilation or the approach to the difficult airway or advanced airway techniques. Endotracheal intubation in the emergency department (ED) setting can be a life-saving intervention. However, this specialized skill requires significant time and effort to both attain and maintain. Unfortunately, in pediatric emergency medicine, we face a training paradox related to ETI. Whereas ETI skills development requires intensive training and repeated opportunities for practice, clinical ETI experiences are infrequent and
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 203
204
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
decreasing. Although health care providers are caring for patients with greater clinical complexity and acuity, opportunities to practice ETI skills are decreasing because of increased use of noninvasive ventilation and decreased trainee work hours in critical care environments. 2 In addition, the opportunities are being diluted by an increased diversity of practitioners (nurses, prehospital providers, physicians, physician assistants, nurse practitioners, nurse anesthetists), residency programs (emergency medicine, neonatology, anesthesia, pediatrics, family medicine), and stages of learning (students, interns, residents, fellows, attending physicians). Even in very high volume tertiary care pediatric EDs (PEDs), there are few ETIs performed by individual pediatric emergency medicine providers. 3,4 Recent literature has demonstrated poor ETI success rates by pediatric providers at the trainee and attending level across premier academic medical centers. 5–9 Serious patient harm occurs when this procedure is not performed efficiently and effectively by the provider. Recent reports note that up to 20% of patients undergoing ETI will suffer harm due to provider performance deficiencies. 6,9–14 Suboptimal performance is associated with a range of complications from mild patient deterioration (hypoxemia) to serious adverse events (tracheal injury) and death. 10,15,16 Technology-enhanced simulation (TES) can help ensure safe ETI practices and optimal patient outcomes. Technology-enhanced simulation should be implemented in EDs to augment clinical opportunities for training, assessment, and maintenance. Simulation provides unlimited opportunities to develop, practice, and refine ETI skills while minimizing risks to real patients. Technologyenhanced simulation is effective for individual provider skills training, team training, and systems optimization. It can be used across the spectrum of providers from novice medical students to experienced attending physicians. Technology-enhanced simulation is a form of experiential learning that activates and engages learners and educators in ongoing feedback during skills development. It can also be used to measure or assess competence and monitor provider skills maintenance over time. The purpose of this article is to provide a clinically relevant comprehensive review of TES related to pediatric health care providers’ ETI skills development, maintenance, and assessment. First, we will discuss ETI skills development; then, we will discuss skills assessment and maintenance. After reading this article, you will be able to describe the use of TES in developing, assessing, and maintaining pediatric health care providers’ ETI
skills (technical and nontechnical). In addition, you will be able to describe how to leverage TES at the systems level to improve the safety of ETI in your ED.
TECHNOLOGY-ENHANCED SIMULATION FOR ETI SKILLS TRAINING Simulators are the materials and/or devices that are used to represent the patient or clinical task. A variety of simulators are available for pediatric ETI training as represented in Table 1. Simulator fidelity is the degree of exactness with which something is reproduced. There are various types of fidelity at the level of the simulator (texture, appearance, movement) and the simulation (context, environment, stress). With increasing clinical experience with real procedures, participants have an increased need for higher fidelity. For example, a medical student may benefit from a static bench top simulator, whereas an attending physician may require a more sophisticated device. Other factors to consider when selecting a simulator include cost and durability for repeated use. Simulation is the technique (not the technology) of mirroring and amplifying real-life situations with guided and interactive experiences. In addition to providing skills training, TES can be used to develop participants’ knowledge about the procedure, confidence, and nontechnical skills such as teamwork. Safe, efficient, and effective ETI performance is also dependent on system factors including the availability of functioning equipment. The rare frequency of pediatric ETI in the clinical setting can be addressed through systems drills. In situ simulations 17 involve training in the actual patient care unit using equipment and resources from that unit with actual team members working together in an announced or unannounced drill. There is substantive evidence that health care providers’ participation leads to acquisition of knowledge or skills when measured in repeated simulation. A meta-analysis demonstrated that TES training is associated with improved outcomes across a range of topics if used under the “right conditions.” These conditions involve the use of specific features rooted in evidence-based instructional design and are listed in Table 2. 18 Cheng et al 19 conducted a pediatric specific meta-analysis that noted that TES was associated with large effects in comparison with no intervention across 57 pediatric studies that involved many of these features. A growing body of evidence is beginning to explore how simulation-based performance impacts downstream outcomes of patients. 20,21
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 205
TABLE 1. Technology-enhanced simulation for pediatric ETI. Modality
Features
Computer-driven models
Sources
Physiologic modeling, audible sounds, swelling of tongue or glottis, chest rise, cyanosis, sensing of ventilation, diverse sizes (neonatal, infant, toddler, child, adult) Static bench-top models Anatomically correct, increased durability, synthetic human tissues, 3D printing, difficult anatomy (micrognathia) Animal/human cadavers Realistic structures if human, challenges with rigor mortis/tone Screen based (computer, tablet, phone, 3D animation, potential for haptic haptics), virtual reality interface, distributed practice at home
Cost
Laerdal, Gaumard, CAE Healthcare
$$$-$$$$
Simulab, Syndaver, Trucorp, Laerdal, Simulaids, Armstrong Medical, Nasco
$-$$$
Anatomy labs, meat supply stores
$
AHA PALS, AAP NRP, Anesoft, MySmartHealthcare
$-$$$
Abbreviations: AAP, American Academy of Pediatrics; AHA, American Heart Association; NRP, Neonatal Resuscitation Program; PALS, Pediatric Advanced Life Support.
There are few examples of TES for pediatric ETI in the literature. One such example, a randomized crossover trial of TES by Sudikoff et al, 22 demonstrated improved global competency and reduced numbers of harmful actions by residents after TES. Another study by Cordero et al 23 outlined improvements in neonatal resuscitation skills and team behavior including management and leadership skills after a single session of deliberate practice. A study by Finan et al 24 noted similar improvements in performance in a simulated setting but did not demonstrate that this translated to increased success rates for clinical performance by the participants. A recent study demonstrated that partic-
ipation in TES increased the frequency of residents performing intubations but did not improve success rates nor reduce adverse events on real patients. This raises concerns that TES may increase provider confidence without increasing competence. 25 The paucity of data demonstrating improvements in pediatric ETI outcomes after simulation could be related to the current equipment (eg, limitations of fidelity include no secretions, no blood, no tone) and/or how the simulations are being conducted (eg, adherence to best educational practices). The following section will review some of the “best practices” related to delivering TES interventions
TABLE 2. INSPIRE framework for endotracheal intubation skills training. 27 1. Learn 2. See 3. Practice
4. Prove
5. Do 6. Maintain
Reading, didactic lectures, discussion of endotracheal intubation (ETI) • Knowledge about indications, contraindications, equipment, anatomy, individual steps of procedure Watching an expert perform ETI on a patient or simulator • Videos such as the New England Journal of Medicine Videos in Clinical Medicine 62 Deliberate practice of ETI on a simulator • Repeated opportunities in a single session • Multiple sessions distributed over time and location (requires access to equipment) • Practice is close in time and space to real patient care and integrated with nonsimulation activities Mastery learning of ETI on a simulator • Independent performance of procedure from start to finish to achieve a minimum passing score in the simulated environment (requires valid tools) Performing ETI on a patient • Independent, correct, and safe performance of a procedure in the clinical environment Repeated performance of ETI on simulator or patient with feedback and reflection • Required at designated time periods by employer
Abbreviation: INSPIRE, International Network for Simulation-Based Pediatric Innovation.
206
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
TABLE 3. Six key features of effective TES with examples for ETI. 18,63,64 Mastery learning 65–72
Reflective practice
Feedback
Deliberate practice
Range of difficulty/clinical variation
Customized/individualized learning
Intensive facilitated training sessions that are not limited by time, involving coached practice, feedback, and correction until a predefined level of performance is achieved Opportunity for the learner to evaluate what went well and what needs to be improved when performing the procedure Specific evaluative information provided by the supervisor to learner with guidance for improvement: “You are hitting the teeth when you lift up toward the ceiling, try angling toward where the wall hits the ceiling.” Highly structured practice with specific goal of improving ETI performance that involves a motivated trainee, hard work, and immediate and repeated formative feedback from an expert in the procedure (eg, anesthesia attending) Range in age (eg, neonatal, infant, child), range of difficulty (eg, micrognathia, cleft, secretions), performing in the presence of family Learning tailored to needs, for example, one individual may need more practice on selecting equipment and another may need more guidance on assembling the team
for pediatric ETI training in the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) framework for procedural skills training. The INSPIRE network is a collaborative working to improve the care of acutely ill children using research to advance simulationbased education. 26 Learn, see, practice, prove, do, maintain (LSPPDM) is a 6-step evidence-based pedagogical framework for procedural skills training, performance and maintenance. It is described in Table 2. 27 This framework contrasts with the traditional mantra of “see one, do one, teach one” in pediatric ETI through the use of TES.
All simulation is not equal: how, where, when, and by whom TES is used play a major role in its effectiveness. The application of TES as a tool in using these techniques offers benefits over reliance on real patient practice. Technology-enhanced simulation allows for frequent presentation of a standardized patient scenario and maximizes safety for the learner, educator, and patient. A series of reviews has described the most effective instructional design features for delivering TES and is summarized with examples related to ETI in Table 3 and described below. Mastery learning involves participants receiving clear objectives for expected performance. They then engage in active learning with coached deliberate practice (see below), during which they perform a procedure and receive immediate formative feedback directed at improving their performance toward the level of the predefined standard. This iterative process continues as a cycle of practice, feedback, and correction. Learners are expected to continue training until skill mastery has been achieved (ie, when the minimum passing score is attained), but the time required to reach this standard is variable. This methodology has been proven to improve performance in clinical procedures such as central line placement, dialysis catheter insertion, thoracentesis, advanced cardiac life support performance, and infant lumbar puncture. Ericsson 28 first used the term deliberate practice and proposed a theoretical construct characterized by continuous remodeling of practice methods to improve performance-based skills and attain expert performance. Hunt et al 29 described the approach of rapid-cycle deliberate practice. The principles of this technique include maximizing hands-on opportunities for learners to perform the “right way,” immediately providing expert feedback and solutions around observed problems, and fostering an environment of “psychological safety” in which the learner may practice.
TECHNOLOGY-ENHANCED SIMULATION TO EVALUATE COMPETENCY The use of TES for ETI competency assessment is attractive, as the infrequency of patient ETI in the ED environment makes clinical competency assessment difficult. In addition, the use of TES for competency assessment allows trainees to “prove” that they are prepared to safely perform the procedure on a patient. Technology-enhanced simulation has a number of features that potentially make it a suitable tool for the assessment of
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 207
practitioner competency and subsequent credentialing. It can increase the validity of the assessment outcome by replicating the environment and complexity of a real clinical PED setting. It offers an error-tolerant and safe environment to complete assessments, thus providing much greater control over assessment content. It also allows for assessment of more complex core competencies related to intubation, especially those involving dynamic interactions, for example, procedural skills and professionalism. Assessment using TES should be supported by strong validity evidence. Determining the validity of an assessment has been detailed by Standards for Educational and Psychological Testing, 30 with content validity, interrater reliability, internal structure of scoring, external validity, and potential consequences of the assessment process all being important components. Cook et al 31 recently conducted a review of simulation-based assessment of health professionals. Skills assessment for CPR and surgical skills dominated this literature, with few studies systematically reporting validity and few studies reporting a comprehensive validity assessment. 31 There are no published studies describing validated assessment of pediatric ETI skills using TES; however, the existing literature does demonstrate some important principles. Firstly, it is unlikely that TES assessments can provide sufficient validity evidence as an isolated assessment methodology without clinical assessments at a later time. Although few studies have directly compared assessment techniques, Nunnink et al 32 assessed intensive care trainees’ ability to manage a blocked tracheostomy using written, simulation-based, and viva voce (oral) examinations. They demonstrated a low correlation between written examination and viva voce or simulation. 32 A small but important proportion of trainees who passed the written examination committed a number of dangerous errors in simulation, thus suggesting that multimodal assessment is likely to be required. 32 Secondly, when developing scoring systems, a global assessment score is an essential addition to checklist-based scoring, as checklists may not identify fundamentally unsafe or unsatisfactory performance. 33 Thirdly, the assessment is likely to be more discriminatory if it includes qualitative measures of skills achievement and allows for demonstration of a whole procedure. This element of validity has been best demonstrated in TES surgical skills assessment; for example, in the assessment of laparoscopic cholecystectomy, “dissection accuracy” was associated with greater experience and skill, but only the full procedure showed complete discrimination between expert and novice. 34
The INSPIRE group has collated the current skills development checklists for pediatric intubation, and work is ongoing to provide validity evidence. Table 4 outlines necessary components of ETI skills assessment. Khaliq 35 has created an objectively structured assessment of technical skills for ETI that demonstrated strong validity evidence in real patients. Andresen et al 36 reported on an ETI assessment tool for medical students. A recent review by Mills et al 37 reported on a systematic review of procedural assessment instruments for pediatric residents. Nishisaki et al 38,39 have described both a task-based scoring instrument and an assessment tool for team, technical, and behavioral skills during ETI. The only validated procedural checklist for neonatal intubation identified in the literature is for nasotracheal intubation, 40 during which an endotracheal tube is passed through the nares. This is different from orotracheal intubation, during which an endotracheal tube is passed through the oropharynx. Bismilla’s 13-item binary nasotracheal procedural checklist was based upon the Neonatal Resuscitation Program guidelines, and content validity was evaluated using a Delphi process. In addition, a 5-point global rating scale was used, with anchors of 1 to 5 corresponding to poor to excellent performance. Two evaluators scored several intubations, and the interrater reliability was calculated. However, specific information about the validation procedure, including details about the Delphi process, correlation between the checklist and global rating scale, the setting of the validation testing (simulated vs clinical environment), training of the raters on the use of the checklists, or results of the statistical analysis, were not presented in the manuscript. 40
Assessment of More Complex Competencies Intubation competency in the PED can be assessed as a discrete skill or may be assessed in
TABLE 4. Intubation skills assessment components. 27 Key Features of Intubation Skills Assessment • Fidelity of technology: Skills trainer and environment have adequate fidelity to replicate the performance of the task. • Content validity of assessment measures • Global rating scale as part of assessment • Qualitative scoring included Time to achieve intubation Correct length of endotracheal placement
208
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
the broader context of patient management. Simulation has been used to “prove” resident competency across a range of domains, in a range of clinical scenarios. 41–43 This literature demonstrates that scenario-based TES assessment can be developed that will have reliability and validity. Assessment of the airway provider in a team simulation has been described, with a task-based scoring instrument, measuring technical and behavioral elements, demonstrating validity 38 of the instrument. However, valid scenario-based PED intubation competency assessment, including matching the scenario-based TES assessment to clinically observed competency, has not yet been reported. It is recommended that those looking to develop scenario-based TES assessment use published tools. The Simulation Module for Assessment of Resident Targeted Event Responses approach was designed to assist with the development of TES assessment of emergency medicine trainees. 44 It provides a systematic method for creating simulation-based scenarios and measurement tools. It emphasizes the need to link to overall objectives, focus on narrow areas of clinical practice, use multiple assessments (ie, sampling), and be specific about how competency is observed while designing and mapping TES scenarios accordingly. 44 A recent review by Brydges et al 20 reported on the link between TES assessments and patient outcomes. Their team noted 33 studies with 24 involving postgraduates, 8 attending physicians, and 6 medical students. These studies demonstrated a strong correlation between simulation and provider behaviors and a small correlation with patient outcomes. Even more complex competencies are team based. However, there is little definitive evidence base for the use of TES for assessment in this area. A comprehensive methodology has been reported to assist with building simulation-based team assessments— Distinguish, Elaborate, Establish, and Proceduralize 45— however, further research is required to validate the output from such an approach. There is very little evidence about the acceptability of TES assessment to those being assessed. Anecdotal experience suggests that it can be acceptable; however, concerns have been raised about the possibility of simulation-based assessment reducing the safety of TES to the learner as a training modality. In one small study of critical care trainees, simulation-based assessment was acceptable to the trainees. 46 Further study is required in this area, particularly among pediatric emergency trainees and more experienced practitioners. It is crucial that educators and faculty provide clear
expectations to trainees about when TES is being used for training and/or assessments. In summary, the use of TES for assessment in pediatric ETI is attractive but remains unproven despite a rapidly developing evidence base. Assessment is most reliable if more than one assessment modality is used (eg, written examination and TES) and a combination of a checklist and a global score is used. Careful planning is required to identify objectives, develop simulation-based experiences, develop scoring systems, and standardize scenario delivery. Further research is required to determine how to assess more complex team-based competencies around intubation in the PED and to assess the acceptability of TES assessment.
USING TECHNOLOGY AND SIMULATION TO IMPROVE ETI QUALITY AND SAFETY In the busy PED environment, emergent airway procedures constitute an area of potential safety concern. These procedures represent an example of a skill performed at low frequency but with high acuity. Beyond the individual ability to attain the skill set required for successful ETI is the maintenance of these skills and resiliency of the environment to minimize the potential for error in each patient encounter. Using the INSPIRE LSPPDM framework for skills training, the transition from “prove” to “do” and ultimately “maintain” is a challenging one. Maintenance of skill over time in ETI is a challenge to the provider, and studies support decay without practice. 47 Data show an average of 63.7 intubations per PED per year, divided among many providers and learners. Among medical directors surveyed, only 62% feel that this is sufficient for skills maintenance. 48 Cognitive task analysis of the process of intubation as performed by anesthesiologists has demonstrated the occurrence of “task omission” but not “task shedding” of the least important elements. 49 Given the inevitable challenges of maintaining skills over time, risk reduction and quality improvement efforts are increasingly essential.
SKILL MAINTENANCE AND EMERGING TECHNOLOGIES Addition of new technology poses additional strain to maintaining mastery for the provider. Storz video laryngoscopes (Karl Storz, Tuttlingen, Germany) use blades and technique similar to traditional direct laryngoscopy. These show promise
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 209
by improving airway views and increasing success in pediatric operating room and general ED settings. 50–52 This technology allows direct supervision of a learner or assistant by projection of the airway views using video display 53 and the possibility of recording for further review and analysis. Likewise, angulated blade indirect video devices such as GlideScope (Verathon, Bothell, WA) allow excellent visualization but require a slightly different technique than traditional direct laryngoscopy. 52–54 Studies have shown similar performance between this technology and direct laryngoscopy. 52,54,55 In the application of novel airway technology, Behringer and Kristensen 53 described an approach to evaluating its implementation: comparison to standard, expected learning curve, and best method to teach proficiency. This may vary by the type of technology implemented, and techniques including simulation should be considered. Additional cycles of skills learning may be required as new technology is introduced.
MULTICENTER QUALITY COLLABORATIVES Currently, attempts to understand the landscape of pediatric intubation across institutions are under way. Given the relative infrequency of this procedure, multicenter data are essential in both understanding the elements of the pediatric difficult airway as well as implementing improvement efforts. The National Emergency Airway Registry for Kids is a multicenter, research-driven collaborative collecting data surrounding pediatric intubations in the intensive care unit, neonatal intensive care unit, and ED settings. Initial data, including 1516 intubations in the pediatric intensive care unit setting, show that 9% of these airway attempts are categorized as “difficult” and are associated with desaturation or more severe tracheal intubation– associated events at much higher rates. 56 Similarly, this collaboration has allowed for the institution of a risk reduction bundle, including 2 pages of items essential to successful airway attempts. This bundle includes preprocedural risk assessment, team-focused generation of a planned approach, preprocedure time out, and a postprocedure huddle for quality improvement opportunities. 57 Such multicenter quality projects provide the benefit of patient volume and rapid best practice dissemination.
VIDEO AND DATA ACQUISITION FOR QUALITY Relative to individual performance and local quality improvement, one current challenge is the reliance upon self-reported data about compli-
cations and challenges. The procedure of ETI is often very rapid and very complex, making even the medical record a potentially unreliable source of information. Many hospitals are beginning to use video recording of resuscitations, including intubations, which allows for more accurate data collection. Kerrey et al 58 reviewed video recordings of 114 intubations in the PED setting and found 61% associated with adverse events. Significant variation existed between data sources. For example, firstattempt success was noted at 52% by video review, 64% by nursing note, and 58% in the procedure note. In addition, a significantly higher frequency of desaturation was noted by video review (33% vs 19%); and only 1 of 2 patients requiring cardiopulmonary resuscitation during intubation had this noted in the medical record. Of note, interrater reliability of video review was excellent. In a study of video review of intubations in an adult trauma unit, the authors noted that “video allows identification of the precursor events, communications, subtle cues, and fine-grained detail of evidence for the link to outcome that are frequently not available through other sources.” 59 This technique allows institutional efforts in quality improvement to address “work as performed, rather than work as imagined.” A study of emergency medicine residents showed that video was superior to individual recall in adherence to institutional rapid-sequence intubation protocol adherence. Only 61% were correct relative to their use of the Sellick maneuver, and only 80% were correct in their recall of use of end-tidal CO2 monitoring. 60 The uses of these video recordings are manifold. These recordings have been used for individual feedback/education, systematic data capture, and process/environment restructuring. 61 Video review can be used to assess the performance of the individual and the system. Few EDs have used a formal review process surrounding the video capture of airway events, but those that have demonstrate the feasibility of this process.
SUMMARY Achieving sufficient skills attainment and maintenance in ETI performance among PED providers is challenging. Trainees initially learning basic skills, as well as providers attaining advanced skills such as mastery of novel airway technology, can use a structured skills attainment approach such as LSPPDM. Within these learning frameworks, the use of TES allows for experience and demonstration at each stage of the process while ensuring safety of
210
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
real patients. In addition, methods including TES and video review can be easily used in quality improvement efforts, including prospective identification of performance errors at the individual and system level. These techniques comprise a practical, safety-focused approach to integration of learning and quality. Acknowledgments The authors wish to thank Charmin Gohel for formatting and building the reference database and for her assistance with editing and providing thoughtful inputs to the manuscript.
REFERENCES 1. World Health Organization. Child mortality. Available at: http://www.who.int/maternal_child_adolescent/topics/child/ mortality/en/. Accessed 4/13/15. 2. DeMauro SB, Millar D, Kirpalani H. Noninvasive respiratory support for neonates. Curr Opin Pediatr 2014;26:157–62. 3. Guilfoyle FJ, Milner R, Kissoon N. Resuscitation interventions in a tertiary level pediatric emergency department: implications for maintenance of skills. Can J Emerg Med 2011;13:90–5. 4. Mittiga MR, Geis GL, Kerrey BT, et al. The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view. Ann Emerg Med 2013;61:263–70. 5. Haubner LY, Barry JS, Johnston LC, et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation 2013;84: 1359–64. 6. Sanders RC, Giuliano JS, Sullivan JE, et al. Level of trainee and tracheal intubation outcomes. Pediatrics 2013;131: e821–8. 7. Nett S, Emeriaud G, Jarvis JD, et al. Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the National Emergency Airway Registry for Children. Pediatr Crit Care Med 2014;15:306–13. 8. Tarquinio KM, Howell JD, Montgomery V, et al. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med 2015;16:210–8. 9. Nishisaki A, Turner DA, Brown CA, et al. A national emergency airway registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med 2013;41:874–85. 10. Easley RB, Segeleon JE, Haun SE, et al. Prospective study of airway management of children requiring endotracheal intubation before admission to a pediatric intensive care unit. Crit Care Med 2000;28:2058–63. 11. Nishisaki A, Ferry S, Colborn S, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med 2012;13:e5-10. 12. Nishisaki A, Marwaha N, Kasinathan V, et al. Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU. Resuscitation 2011;82:386–90.
13. Gomes Cordeiro AM, Fernandes JC, Troster EJ. Possible risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation. Pediatr Crit Care Med 2004;5:364–8. 14. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002;18:417–23. 15. Chen JJ, Susetio L, Chao CC. Oral complications associated with endotracheal general anesthesia. Ma Zui Xue Za Zhi 1990;28:163–9. 16. Gausche M, Lewis RJ. Out-of-hospital endotracheal intubation of children. JAMA 2000;283:2790–2. 17. Patterson MD, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013;22: 468–77. 18. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306:978–88. 19. Cheng A, Lang TR, Starr SR, et al. Technology-enhanced simulation and pediatric education: a meta-analysis. Pediatrics 2014;133:e1313–23. 20. Brydges R, Hatala R, Zendejas B, et al. Linking simulationbased educational assessments and patient-related outcomes: a systematic review and meta-analysis. Acad Med 2015;90:246–56. 21. Zendejas B, Brydges R, Wang AT, et al. Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med 2013;28:1078–89. 22. Sudikoff SN, Overly FL, Shapiro MJ. High-fidelity medical simulation as a technique to improve pediatric residents' emergency airway management and teamwork: a pilot study. Pediatr Emerg Care 2009;25:651–6. 23. Cordero L, Hart BJ, Hardin R, et al. Deliberate practice improves pediatric residents' skills and team behaviors during simulated neonatal resuscitation. Clin Pediatr (Phila) 2013;52:747–52. 24. Finan E, Bismilla Z, Whyte HE, et al. High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol 2012;32:287–92. 25. Nishisaki A, Donoghue AJ, Colborn S, et al. Effect of just-intime simulation training on tracheal intubation procedure safety in the pediatric intensive care unit. Anesthesiology 2010;113:214–23. 26. INSPIRE. International Network for Simulation-based Pediatric Research, Innovation, & Education. Available at: http:// inspiresim.com. Accessed 4/13/15. 27. Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad Med 2015 [in press]. 28. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med 2008;15: 988–94. 29. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, et al. Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training. Resuscitation 2014;85: 945–51. 30. American Educational Research Association. American Psychological Association, National Council of Measurement in Education. Standards for educational and psychological testing. Washington, DC: AERA; 2014. 31. Cook DA, Brydges R, Zendejas B, et al. Technology-enhanced simulation to assess health professionals: a systematic review
TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL. • VOL. 16, NO. 3 211
32.
33.
34. 35.
36. 37.
38.
39.
40.
41. 42. 43.
44.
45. 46.
47.
of validity evidence, research methods, and reporting quality. Acad Med 2013;88:872–83. Nunnink L, Venkatesh B, Krishnan A, et al. A prospective comparison between written examination and either simulation-based or oral viva examination of intensive care trainees' procedural skills. Anaesth Intensive Care 2010;38: 876–82. Hall AK, Pickett W, Dagnone JD. Development and evaluation of a simulation-based resuscitation scenario assessment tool for emergency medicine residents. Can J Emerg Med 2012; 14:139–46. Van Bruwaene S, Schijven MP, Miserez M. Assessment of procedural skills using virtual simulation remains a challenge. J Surg Educ 2014;71:654–61. Khaliq T. Reliability of results produced through objectively structured assessment of technical skills (OSATS) for endotracheal intubation (ETI). J Coll Phys Surg Pak 2013; 23:51–5. Andresen M, Riquelme A, Hasbun P, et al. Evaluation of competencies for tracheal intubation among medical students. Rev Med Chil 2011;139:165–70. Mills DM, Williams DC, Dobson JV. Simulation training as a mechanism for procedural and resuscitation education for pediatric residents: a systematic review. Hosp Pediatr 2013; 3:167–76. Nishisaki A, Donoghue AJ, Colborn S, et al. Development of an instrument for a primary airway provider's performance with an ICU multidisciplinary team in pediatric respiratory failure using simulation. Respir Care 2012;57:1121–8. Nishisaki A, Nguyen J, Colborn S, et al. Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit. Pediatr Crit Care Med 2011;12:406–14. Perlman JM, Wyllie J, Kattwinkel J, et al. Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Pediatrics 2010; 126:e1319–44. Blum RH, Boulet JR, Cooper JB, et al. Simulation-based assessment to identify critical gaps in safe anesthesia resident performance. Anesthesiology 2014;120:129–41. Fehr JJ, Boulet JR, Waldrop WB, et al. Simulation-based assessment of pediatric anesthesia skills. Anesthesiology 2011;115:1308–15. Sidi A, Baslanti TO, Gravenstein N, et al. Simulation-based assessment to evaluate cognitive performance in an anesthesiology residency program. J Grad Med Educ 2014;6: 85–92. Rosen MA, Salas E, Silvestri S, et al. A measurement tool for simulation-based training in emergency medicine: the simulation module for assessment of resident targeted event responses (SMARTER) approach. Simul Healthc 2008;3:170–9. Grand JA, Pearce M, Rench TA, et al. Going DEEP: guidelines for building simulation-based team assessments. BMJ Qual Saf 2013;22:436–48. Nunnink L, Foot C, Venkatesh B, et al. High-stakes assessment of the non-technical skills of critical care trainees using simulation: feasibility, acceptability and reliability. Crit Care Resusc 2014;16:6–12. Kovacs G, Bullock G, Ackroyd-Stolarz S, et al. A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Ann Emerg Med 2000;36:301–9.
48. Losek JD, Olson LR, Dobson JV, et al. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care 2008;24:294–9. 49. Mackenzie C, Xiao Y, Horst R. Video task analysis in high performance teams. Cogn Technol Work 2004;6:139–47. 50. Vlatten A, Aucoin S, Litz S, et al. A comparison of the Storz video laryngoscope and standard direct laryngoscopy for intubation in the pediatric airway—a randomized clinical trial. Paediatr Anaesth 2009;19:1102–7. 51. Sakles JC, Mosier JM, Chiu S, et al. Tracheal intubation in the emergency department: a comparison of GlideScope(R) video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med 2012;42:400–5. 52. Karsli C, Der T. Tracheal intubation in older children with severe retro/micrognathia using the GlideScope Cobalt infant video laryngoscope. Paediatr Anaesth 2010;20:577–8. 53. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66:57–64. 54. Redel A, Karademir F, Schlitterlau A, et al. Validation of the GlideScope video laryngoscope in pediatric patients. Paediatr Anaesth 2009;19:667–71. 55. Fonte M, Oulego-Erroz I, Nadkarni L, et al. A randomized comparison of the GlideScope videolaryngoscope to the standard laryngoscopy for intubation by pediatric residents in simulated easy and difficult infant airway scenarios. Pediatr Emerg Care 2011;27:398–402. 56. Graciano AL, Tamburro R, Thompson AE, et al. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med 2014;40:1659–69. 57. Li RP, Xue FS, Wang SY, et al. Comparing performance of video and direct laryngoscopes for intubation during prehospital cardiopulmonary resuscitation. Am J Emerg Med 2014;32:472–3. 58. Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med 2012;60:251–9. 59. Mackenzie CF, Xiao Y, Hu FM, et al. Video as a tool for improving tracheal intubation tasks for emergency medical and trauma care. Ann Emerg Med 2007;50:436–42. 60. Olsen JC, Gurr DE, Hughes M. Video analysis of emergency medicine residents performing rapid-sequence intubations. J Emerg Med 2000;18:469–72. 61. Mackenzie CF, Xiao Y. Video techniques and data compared with observation in emergency trauma care. Qual Saf Health Care 2003;12 (Suppl 2):ii51–7. 62. Kabrhel C, Thomsen TW, Setnik GS, et al. Orotracheal intubation video. NEJM 2007;356:e15. Available at: http:// www.nejm.org/doi/full/10.1056/NEJMvcm063574. Accessed 4/14/15. 63. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28. 64. McGaghie WC, Issenberg SB, Petrusa ER, et al. A critical review of simulation-based medical education research: 2003-2009. Med Educ 2010;44:50–63. 65. Barsuk JH, Cohen ER, Feinglass J, et al. Use of simulationbased education to reduce catheter-related bloodstream infections. Arch Intern Med 2009;169:1420–3. 66. Kessler DO, Auerbach M, Pusic M, et al. A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills. Simul Healthc 2011;6:197–203.
212
VOL. 16, NO. 3 • TECHNOLOGY-ENHANCED SIMULATION TRAINING FOR PEDIATRIC INTUBA... / EMERSON ET AL.
67. Barsuk JH, McGaghie WC, Cohen ER, et al. Use of simulationbased mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med 2009;4:397–403. 68. Wayne DB, Barsuk JH, O'Leary KJ, et al. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54. 69. Wayne DB, Fudala MJ, Butter J, et al. Comparison of two standard-setting methods for advanced cardiac life support training. Acad Med 2005;80:S63–6.
70. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006;21:251–6. 71. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med 2005;17:210–6. 72. Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a casecontrol study. Chest 2008;133:56–61.