Simulation in pediatric anesthesiology

Transcription

1 Pediatric Anesthesia ISSN REVIEW ARTICLE James J. Fehr 1, Anita Honkanen 2 & David J. Murray 3 1 Department of Anesthesiology and Pediatrics, Washington University School of Medicine, St Louis, MO, USA 2 Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA, USA 3 Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA Keywords simulation; education; quality improvement; outcomes Correspondence James J. Fehr, Department of Anesthesiology and Pediatrics, Washington University School of Medicine, St Louis Children s Hospital, One Children s Place, 5S31, St Louis, MO 63110, USA fehrj@wustl.edu Section Editor: Andrew Davidson Accepted 19 July 2012 doi: /pan Summary Simulation-based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer-based simulations to mannequins. Computer-controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in-situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task-training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients. Introduction Computer-controlled patient simulators have evolved tremendously since the description in 1969 of the SimOne simulated patient by Denson (1). Highly technological computer-driven simulators titillate students but goals that Denson envisioned for future simulators remain elusive for currently available pediatric simulators that lack color change of skin and mucous membranes, the tongue falling into the pharynx, intercostal retractions, and forehead responsiveness to light anesthesia. Pediatric mannequin fidelity lags behind the 988 adult counterparts primarily because of the technical difficulties in translating mechanical features that are possible in a large mannequin to the scale of a neonate or infant. Unfortunately, critical educational requirements for pediatric perioperative and critical care occur in the infant and toddler age group. The field of anesthesiology, with its focus on patient safety and reliance on advanced technology, has been a forerunner in the continuing development of simulation. Recently, simulation has been incorporated as a component of Maintenance of Certification in Anesthesiology [MOCA] program. Pediatric anesthesiology will soon have its

2 J.J. Fehr et al. own board certification, and efforts are underway made to incorporate pediatric components into the MOCA. The purpose of this report is (i) to describe the various domains in perioperative pediatric practice where simulation has been developing, (ii) to review research developments in simulation that impact pediatric anesthesiology, and (iii) to consider the future ways in which simulation-based training and evaluation may come to bear on the education and continuing assessment of pediatric anesthesiologists. Simulation in anesthesiology The commitment of anesthesiologists to patient safety was recognized in To Err is Human (2). This treatise by the Institute of Medicine on the inherent dangers of modern medical care was a signal flare highlighting an ongoing crisis, which was echoed a decade later by Landrigan who noted that there had been little widespread improvement in the intervening years (3). Every day anesthesiologists confront the interventions patients endure and contend with the complications of medical care. They have been pioneers of simulation education, recognizing the essential need to practice critical skills in a manner that does not put patients at risk. Denson s SimOne is the forerunner of many of the electromechanical simulators in current use. Safar and Elam s Resusci Annie has been used to train acute care providers around the world for the last half a century. Simulation tools and techniques range from task trainers to standardized patients and from computer-based simulations to computer-driven mannequins. These can be used in isolation or in combination depending on the curricular goals for the target trainees (Table 1). Simulation-based education has dispersed throughout the medical system with anesthesiologists adapting crew resource management principles developed by NASA in response to airline crashes. Crisis Resource Management [CRM] principles, first promulgated by Gaba at Stanford in the early 1990s, have been incorporated into the simulationbased education programs throughout the world (4). Simulation has been incorporated into residency and fellow training, has been used to train new staff, and provides a venue for continuous medical education for experienced physicians (5). Simulation has bolstered continuous quality improvement programs and been utilized to evaluate new technologies. As an experiential educational format, simulation allows individuals to learn through deliberative practice, to receive direct and immediate feedback, and to address without delay any areas that require remediation. Proper attention to structure and supportive debriefing optimizes the learning experience (6). Table 1 Applications of simulation modalities Simulation Modality Full-Size electromechanical mannequin Task-training devices Standardized patients Simulation for clinical skills Pediatric Anesthesia Curriculum Applications Team Training Activities (In Situ Versus In-Center Curriculum) Pediatric Advanced Life Support (PALS) Neonatal Resuscitation Program (NRP) Rapid response teams Pediatric transport teams Pediatric trauma teams ECMO Acute Care Management Decisions Situational awareness Differential diagnosis Setting management priorities Implementing therapy Pediatric Procedures Airway management Vascular access Lumbar puncture Chest tube placement Difficult Conversations Disclosure of error Family anger Limitations of care Do not resuscitate decisions The practical implementation of simulation training for pediatric anesthesiology would include a curriculum in various task training activities that could be used to develop many of the special skill sets required for the child. The skill sets in airway management, central venous and vascular access, vascular access and ultrasound-guided regional anesthetic techniques share considerable overlap with those skills that many of our residents, fellows, and anesthesiologists acquire and practice in the adult population. While the skills likely generalize from the adult to the child, there are unique considerations in pediatrics that require specific training and experience. For example, the principles of central venous line insertion or rapid sequence induction and airway management for an adult would be expected to share some similarities to those in a 3-kg infant, but few would suggest that the skills are comparable that an anesthesiologist could effectively manage these tasks in children if they have previously only performed the procedures in adults. A set of task-training skills that could be used to provide experiences in developing skills with pediatric patients is presented in Table 2. The simulated clinical setting offers the proper milieu to demonstrate and experience many of the advanced subspecialty and complex skills needed by specialists 989

3 J.J. Fehr et al. Table 2 Task-training skills in pediatric anesthesiology Airway Difficult Pediatric Airway Ventilation Vascular Access Fluid Administration Pediatric Dysrhythmias Regional anesthetic techniques Various sizes of intubating heads, masks and laryngoscopes, oral and nasal airways, endotracheal tubes and laryngeal mask airways Bag and mask ventilation skills Endotracheal intubation Emergency airway management in children Alternatives to direct laryngoscopy Fiberoptic laryngoscopy Cricothyrotomy Pediatric ventilator management Jet ventilation Lung separation techniques in children Central line trainers Intraosseous line placement Rapid infusion devices Fluid warming devices Defibrillation Caudal, injection and caudal catheter techniques, spinal anesthesia, infant epidural caring for sick children. One step in the process involves the evaluation of practice ability. Candidates can demonstrate this practice performance assessment and improvement (PPAI) at accredited simulation centers. Currently, the primary role of PPAI has been the demonstration of clinical and teamwork competencies, especially in recognizing and managing crises and maintaining their expertise in handling uncommon events. The scenario is the fundamental building block of the simulation-based assessment. Scenarios must be constructed with a solid awareness of content and curricular objectives. The steps to developing scenarios include (i) selecting competence domains that are amenable to a simulation environment, (ii) defining the expected skills that are needed to diagnose and manage the crisis, (iii) designing a scenario that has the required skills embedded into the framework, and (iv) constructing the scenario with expert consensus and a framework expected by the specialist. Scenarios that sample the knowledge and skills necessary to optimally manage a particular clinical condition are the best to meet education needs and offer the potential to improve the outcome of children who endure these conditions. The core curriculum of the expected skill sets for resident anesthesiologists who care for children could serve as a source for scenario content (7). One of the advantages of a prospective curricular design is that recommendations of experts can be incorporated with attention to the sequence and timing of each step in a real time simulation environment. A simulation exercise based on the 990 expected skills noted in this core curriculum might include a scenario that entails the induction and airway management of an infant with intussception that would meet the skill expectations for managing an infant with a full stomach. A scenario designed around the sudden development of postoperative apnea in a neonate would provide a method to develop or assess skills in managing the premature infant. With the wide range of ages, sizes, developmental issues encountered in pediatric practice, no trainee is likely to experience all of the manifestations of pediatric practice during residency or even during a pediatric anesthesiology fellowship. Simulation helps close that gap by exposing trainees to a vast domain of potential conditions. The Wake Up Safe pediatric quality initiative includes a statement about the risks of hyperkalemia associated with the rapid transfusion of blood (8). A scenario designed around this quality initiative not only provides anesthesiologists with the skills needed to recognize hyperkalemia associated with rapid transfusion, but provides an experience on how to manage this serious intraoperative condition. The scenario that progresses to cardiac arrest would include the need to initiate a Pediatric Advanced Life Support (PALS) algorithm. This type of design can be used to provide experiences in managing cardiac arrest and offers a method for specialists to demonstrate a variety of widely recognized competence domains (9,10). Hyperkalemia is a life-threatening severity event, and the impact on pediatric practice could be profound if a physician s simulation experiences improve the outcome of a child who suffers from a hyperkalemic arrest. Scenarios designed around various causes of hypotension in a 10-kg child could be used to develop skills in differential diagnosis of cardiovascular conditions in a child. For example, during a neuroblastoma resection, scenarios could be designed that include the range of differential diagnostic possibilities. The cardiovascular events might include hemorrhage, hyperkalemia, hypocalcemia associated with blood replacement, latex allergy, transfusion reaction, arrhythmia, vena cava compression, tumor embolism, or air embolism. The multiple scenario framework around a high-acuity clinical event such as hypotension often provides a method to develop effective management skills for some of the most serious pediatric events. Other potential scenarios for pediatric training are presented in Table 3. One of the main roles for simulation training is to optimize team interactions as individual expertise does not equate to effective team performance. Teams are defined as two or more individuals who share a common goal. To accomplish common team goals, each team member has a particular role, is responsible for specific

4 J.J. Fehr et al. Table 3 Scenarios to enhance clinical decision making in pediatric anesthesiology Scenario Bronchospasm Hyperkalemia Air Embolus Anaphylaxis Laryngospasm Airway Foreign Body Newborn Resuscitation Unresponsive Infant Postoperative Apnea Accidental Extubation Scenario descriptor 10-year-old/30-kg asthmatic with sickle cell disease is wheezing postoperatively A 3-month-old who is undergoing craniosynostosis repair and experiences a sudden, massive blood loss. Rapid transfusion of blood results in a hyperkalemic cardiac arrest. A 3-year-old with tricuspid atresia who is status post-glenn procedure undergoes inguinal hernia repair. Caudal is performed. Child suffers a cardiac arrest after right foot IV is flushed At the beginning of orthopedic surgery for removal of lower extremity hardware a 5-year-old/20 kg develops hypotension and is difficult to ventilate. Laryngeal mask airway is in place. Progressive hypotension and worsening hypoxia develop with facial edema. A 4-year-old/15-kg child develops a cough and breath holding during a mask case, progresses to laryngospasm. A 4-year-old/15-kg child preoperative for myringotomy tubes has a cough. Nurse is concerned. Mannequin with unilateral breath sounds and not on monitor. Resuscitation of just delivered 2 kg newborn. Born less than a minute ago, baby has no respiratory effort, decreased tone, heart rate <60, and poor perfusion. A code is called for a 4-week-old/3.5-kg infant found unresponsive on the general pediatrics ward 3-month-old/3-kg former 26-week premature having apnea and bradycardia in postanesthesia care unit (PACU) following hernia repair. 1-month-old/3-kg infant has accidental extubation during an MRI tasks, and exchanges of information in timely and accurate fashion. Highly functioning teams have a range of contingency plans when a critical event occurs and recognize and adapt to a changing situations. Examples of how team functioning is essential in pediatric anesthesia practice include the coordinated interplay in separating from cardiopulmonary bypass settings, sharing the airway for foreign body removal, and pediatric trauma resuscitation. For many of these activities, some of the most effective training experiences occur in the in situ setting. In situ pediatric simulation In situ simulation involves scenarios that are run in participants usual clinical environment and offers two key practical advantages over events run at simulation centers: affordability (11) and easier access to personnel, by bringing the simulation experience to the participants rather than asking them to travel to an offsite simulation center. There are several substantive advantages related to the types of assessments that can be performed. The environment of care can be examined for system flaws, team dynamics can be evaluated (12), and the participants experience is improved by increased plausibility and comfort working within their usual care milieu. In situ simulations can improve patient safety by educating healthcare providers through exposure of latent system errors and protocol deficiencies. At Cincinnati Children s Hospital, simulation was used to identify latent system errors, evaluate provider workloads, and understand team member responsibilities prior to the opening of a new satellite hospital. Multiple changes in protocols, task assignment, staffing, and the care environment were made prior to introducing patients to the facility (13). Similarly, at Lucile Packard Children s Hospital, a series of team simulations completed prior to the opening of a new operating room suite helped define a punch list of hundreds of identified equipment and process deficiencies, all addressed before the first real patient received surgery there. Team training to examine and improve management of a lost-airway by each surgical specialty team was completed over the course of a year using in situ simulation at Stanford. Changes to equipment sets for emergent tracheostomy, role clarification, and a new difficult-airway protocol were all results of this series of simulations. Johns Hopkins use simulation to evaluate their code teams response to a series of pediatric mock codes throughout their facilities. Delays, deviations from the American Heart Association pediatric basic life support protocols, and communication errors were noted (14). Simulations of pediatric trauma responses were also examined and showed similar deficiencies in stabilization techniques and skills in emergency department personnel (15). These simulations identified several educational opportunities for team members. At Children s Hospital of Philadelphia, Just-in-time intubation training using high-fidelity pediatric mannequins was implemented in the pediatric intensive care unit, to attempt to increase the rate of successful intubation without adverse events for trainees rotating through the unit. They found that there was no change in the number of major or minor tracheal intubation-associated events after implementation of the training (16), 991

5 J.J. Fehr et al. possibly due to the need for more in-depth training to develop mastery. However, they did note an increase in the subsequent exposure of trainees to intubation opportunities, thus facilitating acquisition of this skill for the trainees during the remainder of their rotation. There are drawbacks to in situ simulations including the competition for clinical space: a simulation event may be planned in a certain area that is then needed unexpectedly for actual patient care. Similarly, participants may be pulled from the simulation event for actual patient care. Thorough communication with participant team members and support from the clinical area management team are crucial to implement a successful in situ program. An additional disadvantage is the limited curriculum and preparation that is associated with in situ simulations. Often the goal is to evaluate current capabilities, so usually a single unplanned scenario is the norm. Thus, participants do not experience the range of complex and challenging scenarios that are needed to acquire or assess skill in a domain of practice. In addition, participants need the reinforcement and repetition to acquire skills in this type of experiential learning setting. While the in situ approach offers considerable advantages in incorporating a high-fidelity realistic simulation, the curriculum is primarily team specific and primarily addresses team and system-related clinical care considerations. The Society for Pediatric Anesthesia introduced a high-fidelity pediatric simulation workshop in 2007, at an in situ operating room environment in Phoenix Children s Hospital. The goals were focused not only on introduction of the simulation technique for education, but also Anesthesia Crisis Resource Management (ACRM) concepts and systems analysis. Participants were able to help manage the crisis or assist in the analysis of the event during the debriefing. Subsequent SPA workshops have focused on leadership development, the maintenance of infrequently used skills, and developing reflective practice. One of the limiting factors in running high-fidelity simulations at conferences is the restricted number of individuals that can actively participate during the scenarios because of the considerable logistical challenges, the potential cost of equipment, and the substantial commitment of faculty time to successfully run multiple scenarios. In 2011, a new approach was introduced at the SPA annual meeting, adapted from the Sim Wars model created by Y. Okuda with Emergency Medicine simulations (17). Two teams competed in running through the same scenario in front of the audience. Debriefing by expert judges focused on effective communication, team leadership, and medical management and allowed the audience to consider how learning in 992 simulation occurs and how CRM skills are evaluated. The evolution of the approach to teaching simulation concepts and demonstrating high-fidelity simulation techniques in Pediatric Anesthesia, from in situ operating room simulation, to conference center small group training, to whole audience demonstration reflects the broadening of the use of simulation techniques throughout our specialty. As the MOCA simulation requirement continues, these experiences will become a regular part of our collective practice, and education in how to effectively use and participate in simulation will grow in demand. Research into simulation-based education and assessment in pediatrics Extensive research has been performed to evaluate the effect of medical simulation on patient outcomes, educational outcomes, and team performance. There has also been significant research into the operation and optimal debriefing techniques. Pediatric simulation has burgeoned through efforts of pediatric specialists in intensive care, emergency medicine, anesthesiology, and many other pediatric specialties. This new paradigm has brought in situ simulation and crisis resource management into pediatric intensive care units, with training of residents, fellows, nurses, and other staff (18). Simulation in the pediatric realm has focused on the evaluating and improving the performance of individuals and teams in adhering to established guidelines of PALS and the Neonatal Resuscitation Program. Miscommunication and absence of a shared mental model are major causes of team failure, which crew resource management training can remediate (19). Multiscenario assessments have been utilized to evaluate pediatric residents performing acute care management of simulated pediatric patients (20). Standardized patients have been used to teach pediatric residents to assess adolescent suicide risk (21). Simulation has also been incorporated into the training of pediatric trauma response teams (22), and team function has improved with video review of simulated trauma resuscitation (23). Simulation has also been used to evaluate the performance of anesthesiology residents and pediatric anesthesia fellows at acute care pediatric anesthesia tasks (24). A multi-institutional Boot Camp for first-year pediatric ICU fellows utilizing task trainers, and high- and lowfidelity simulation was felt to improve self-confidence and clinical performance by the participants in followup surveys (25). The EXPRESS network, a collaborative research network, has been established to aid the performance of research studies using simulation in pediatrics (26).

6 J.J. Fehr et al. The future of simulation in pediatric anesthesiology Despite significant enthusiasm by advocates of medical simulation, there remains no direct evidence that simulation training improves patient outcomes (27). The costs associated with the use of simulation are substantial and include the mannequins and their ongoing maintenance, faculty time, and staff support. To convince skeptical colleagues in times of financial pressure, these costs must be justified by better educational outcomes, by improved patient outcomes, and by incorporation of simulation as an assessment modality. The future of simulation for pediatric anesthesiology will require demonstration of improvement in outcomes in the educational, patient care and clinical care delivery domains. As the point is to positively impact patient care, scenario development should derive from untoward events that have occurred or have been identified thorough mortality and morbidity reporting or near misses. Ideally, continuous quality improvement initiatives would lead prospective change through simulation design, which address identified potential hazards. Having identified areas for simulation development, the scenarios that reflect this content should derive from evidence-based research and expert consensus opinion. An evidence-based approach would provide the broadest utility for simulation, both nationally and internationally. Such an approach has been developing in the United Kingdom and now in Canada with the MEPA program for registrars (28). The combination of an evidence-based set of scenarios that are combined with an expert consensus about effective management would provide a curriculum that benefits subspecialty practice in pediatric anesthesiology. Conclusion Simulation can identify areas where practitioners are deficient, and ongoing research is better delineating those areas where simulation makes the most beneficial impact. Collaborative endeavors such as the pediatric EXPRESS research network provide and MEPA educational programs provide an international framework for simulation projects. The incorporation of simulation into training programs continues unabated and improved standards of evidence-based simulation scenarios will ideally provide a window in the performance of pediatric anesthesiologists at various stages of their career. Acknowledgments This study was supported by the Agency for Healthcare Research and Quality, Grant R01 HS Conflict of interest No conflicts of interest declared. References 1 Denson JS, Abrahamson S. A computercontrolled patient simulator. JAMA 1969; 208: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, Landrigan CP, Parry GJ, Bones CB et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363: Howard SK, Gaba DM, Fish KJ et al. 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