Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: Identification of targets for performance improvement

Department of Surgery, Duke University, Durham, North Carolina, United States
PEDIATRICS (Impact Factor: 5.47). 04/2006; 117(3):641-8. DOI: 10.1542/peds.2004-2702
Source: PubMed


Trauma is the leading cause of death in children. Most children present to community hospital emergency departments (EDs) for initial stabilization. Thus, all EDs must be prepared to care for injured children. The objectives of this study were to (1) characterize the quality of trauma stabilization efforts in EDs and (2) identify targets for educational interventions.
This was a prospective observational study of simulated trauma stabilizations, that is, "mock codes," at 35 North Carolina EDs. An evaluation tool was created to score each mock code on 44 stabilization tasks. Primary outcomes were (1) interrater reliability of tool, (2) overall performance by each ED, and (3) performance per stabilization task.
Evaluation-tool interrater reliability was excellent. The median number of stabilization tasks that needed improvement by the EDs was 25 (57%) of 44 tasks. Although problems were numerous and varied, many EDs need improvement in tasks uniquely important and/or complicated in pediatric resuscitations, including (1) estimating a child's weight (17 of 35 EDs [49%]), (2) preparing for intraosseous needle placement (24 of 35 [69%]), (3) ordering intravenous fluid boluses (31 of 35 [89%]), (4) applying warming measures (34 of 35 [97%]), and (5) ordering dextrose for hypoglycemia (34 of 35 [97%]).
This study used simulation to identify deficiencies in stabilization of children presenting to EDs, revealing that mistakes are ubiquitous. ED personnel were universally receptive to feedback. Future research should investigate whether interventions aimed at improving identified deficiencies can improve trauma stabilization performance and, ultimately, the outcomes of children who present to EDs.

4 Reads
  • Source
    • "Simulation performed within a clinical enviroment, in situ simulation, is particularly suitable to identify system weaknesses or errors and to perform context-sensitive assessments. By bringing simulation into the clinical enviroment, it is possible to identify and prevent adverse events that could compromise patient safety [20-22]. Furthermore, in situ simulation represents a cost-effective opportunity in medical education and several studies report the utility of simulation training for acquisition of skills and knowledge with retention across different specialities [23-25]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Interruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted recently. Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial. By implementing in situ simulation we created a model to evaluate resuscitation performance. The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team. A prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted. The participants of the study involved all health care personel on duty who responded to a cardiac arrest. We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team. Data from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349). A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001. The difference was significant even after adjusting for pulse and rhythm check and shock delivery. The main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR. Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 10/2011; 19(1):55. DOI:10.1186/1757-7241-19-55 · 2.03 Impact Factor
  • Source
    • "The team performance showed improvement in overall simulation survival rate and task completion rate from 0% to 90% and from 31% to 89%, respectively. Hunt and colleagues [62] used simulated trauma stabilization ''mock codes'' successfully to identify deficiencies in stabilization of children with trauma presenting to the hospital emergency departments. Evaluation tool interrater reliability was excellent, and 57% of the stabilization tasks needed improvement (estimating a child's weight, preparing for intraosseous needle placement, ordering fluid boluses, applying warm measures, and ordering dextrose for hypoglycemia). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Outcomes from pediatric cardiac arrest and cardiopulmonary resuscitation (CPR) seem to be incrementally improving. The past 2 decades have brought advances in the understanding of the pathophysiology of cardiac arrest and ventricular fibrillation, better treatment strategies, and a more robust standard for CPR epidemiology and research reporting. The evolution of practice based on an improved understanding of the pathophysiology and timing, intensity, duration, and variability of the hypoxic-ischemic insult should lead to goal-directed therapy gated to the phase of cardiac arrest and the postarrest period encountered. By strategically focusing therapies to specific phases of cardiac arrest and resuscitation and to the evolving pathophysiology and by implementing evidence-based practice, there is great promise that critical care interventions can lead the way to more successful cardiopulmonary and cerebral resuscitation in children.
    Pediatric Clinics of North America 09/2008; 55(4):1051-64, xii. DOI:10.1016/j.pcl.2008.04.013 · 2.12 Impact Factor
  • Source
    • "A study of simulated mock traumas performed at 35 North Carolina emergency departments revealed problems with pediatric-specific tasks, such as appropriate use of intraosseous needles, weight-based dextrose and volume replacement, and poor preparation for transport to CT. In this study, teams were 315 SIMULATION AND TEAMWORK evaluated to identify possible targets for educational and system-wide interventions that might have the potential to improve the outcomes of pediatric trauma victims [47]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Traditional medical education has emphasized autonomy, and until recently issues related to teamwork have not been explicitly included in medical curriculum. The Institute of Medicine highlighted that health care providers train as individuals, yet function as teams, creating a gap between training and reality and called for the use of medical simulation to improve teamwork. The aviation industry created a program called Cockpit and later Crew Resource Management that has served as a model for team training programs in medicine. This article reviews important concepts related to teamwork and discusses examples where simulation either could be or has been used to improve teamwork in medical disciplines to enhance patient safety.
    Anesthesiology Clinics 07/2007; 25(2):301-19. DOI:10.1016/j.anclin.2007.03.004
Show more