Effect Of High-Fidelity Simulation On Pediatric Advanced .
ORIGINAL ARTICLEEffect of High-Fidelity Simulation on Pediatric Advanced LifeSupport Training in Pediatric House StaffA Randomized TrialAaron J. Donoghue, MD, MSCE,*Þ Dennis R. Durbin, MD, MSCE,* Frances M. Nadel, MD, MSCE,*Glenn R. Stryjewski, MD,þ Suzanne I. Kost, MD,§ and Vinay M. Nadkarni, MD, MSÞObjectives: To assess the effect of high-fidelity simulation (SIM) oncognitive performance after a training session involving several mockresuscitations designed to teach and reinforce Pediatric Advanced LifeSupport (PALS) algorithms.Methods: Pediatric residents were randomized to high-fidelitysimulation (SIM) or standard mannequin (MAN) groups. Each subjectcompleted 3 study phases: (1) mock code exercises (asystole,tachydysrhythmia, respiratory arrest, and shock) to assess baselineperformance (PRE phase), (2) a didactic session reviewing PALSalgorithms, and (3) repeated mock code exercises requiring identicalcognitive skills in a different clinical context to assess change in performance (POST phase). SIM subjects completed all 3 phases using ahigh-fidelity simulator (SimBaby, Laerdal Medical, Stavanger, Norway),and MAN subjects used SimBaby without simulated physical findings(ie, as a standard mannequin). Performance in PRE and POST wasmeasured by a scoring instrument designed to measure cognitiveperformance; scores were scaled to a range of 0 to 100 points.Improvement in performance from PRE to POST phases was evaluatedby mixed modeling using a random intercept to account for withinsubject variability.Results: Fifty-one subjects (SIM, 25; MAN, 26) completed all phases.The PRE performance was similar between groups. Both groups demonstrated improvement in POST performance. The improvement in scoresbetween PRE and POST phases was significantly better in the SIM group(mean [SD], 11.1 [4.8] vs. 4.8 [1.7], P 0.007).Conclusions: The use of high-fidelity simulation in a PALS trainingsession resulted in improved cognitive performance by pediatric housestaff. Future studies should address skill and knowledge decays and teamdynamics, and clearly defined and reproducible outcome measuresshould be sought.Key Words: PALS, education, simulation(Pediatr Emer Care 2009;25: 139Y144)Resuscitations for pediatric patients are uncommon occurrences. Pediatric house staff have scant experience in leadingactual patient resuscitations during their residency.1 Educationalexercises involving mock patients with critical illness, often referred to as mock codes, have been used for decades to trainFrom the Divisions of *Emergency Medicine, and †Critical Care Medicine,The Children’s Hospital of Philadelphia, PA; and Divisions of ‡Critical CareMedicine, and §Emergency Medicine, A.I. duPont Hospital for Children,Wilmington, DE.Reprints: Aaron Donoghue, MD, MSCE, Divisions of Emergency Medicineand Critical Care Medicine, The Children’s Hospital of Philadelphia,Room AS24, 34th St and Civic Center Blvd, Philadelphia, PA 19104(e-mail: donoghue@email.chop.edu).This project was supported by an award from the Laerdal Foundation forAcute Medicine.Copyright * 2009 by Lippincott Williams & WilkinsISSN: 0749-5161Pediatric Emergency Care&house staff in the principles of care of children with criticalillness. Studies have shown these exercises to improve confidence and performance in pediatric house staff.2High-fidelity simulation is a rapidly evolving technologythat has been in use for years in a variety of medical fields.Within medicine, the most robust experience with this technology are in anesthesia, where it has been used for training andmaintenance of competency and certification.3 High-fidelitysimulation is well suited to training for critical clinical situationsthat are uncommon but for which a level of preparedness isessential. The goal of a high-fidelity simulation experience is toallow the participants to suspend disbelief and perform in amanner that more closely reflects the way they would act incaring for a real patient in a comparable situation. Previousstudies have examined the effect of simulation exercises on taskperformance, the dynamics of team interactions, and overallperformance of trainees after training programs.4Y9 The childwith critical illness or injury fits this educational paradigm well,and published literature on the effectiveness of simulationtechnology in pediatrics is beginning to emerge.7,10We designed a study to evaluate the effect of a high-fidelitysimulation milieu during a training session in Pediatric AdvancedLife Support (PALS) algorithms targeted toward junior pediatricresidents. The outcomes of interest centered on performance ofcritical cognitive tasks in a set of standardized mock code scenarios. Our hypothesis was that the use of high-fidelity simulation features would result in enhanced cognitive performance.METHODSResidents at 3 tertiary children’s hospitals were invitedto participate. Eligible participants were pediatric house staff atthe level of postgraduate year 1 or 2 during the period fromMay 2006 through January 2007. All residents approached forthe study must have completed at least 5 months but no morethan 14 months of residency training; all residents meeting thesecriteria were reached by e-mail and invited to volunteer to participate. Baseline data collected on each participant includedtheir prior participation in resuscitations, their clinical procedural experience, and their experience with mock code exercisesin the past (with or without simulators). After written informedconsent, participants were randomized within study site andpostgraduate level to either the simulator (SIM) or mannequin(MAN) groups. Block randomization via a web-based randomnumber generator (www.random.org) was used; neither investigators nor subjects were blinded to group assignment.Each study session was divided into 3 phases (Fig. 1). Thefirst phase (PRE phase) consisted of 4 case scenarios designedto require the performance of cognitive tasks pertinent to clinicalassessment and intervention (hereafter referred to as criticaltasks) according to different PALS algorithms. Each PRE phaseVolume 25, Number 3, March 2009Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.139
Donoghue et alPediatric Emergency Care&Volume 25, Number 3, March 2009FIGURE 1. Schematic of trial phases and list of critical tasks.scenario was allowed to run up to 5 minutes or until all criticaltasks were performed, whichever occurred first. The secondphase consisted of a scripted didactic review of the text and flowdiagrams for PALS algorithms for basic life support, pulselessarrest, tachycardia with poor perfusion, respiratory arrest, andshock. Time was provided for questions and answers after thereview. The third phase (POST phase) consisted of 2 additionalscenarios designed to require the same set of tasks as the PREphase scenarios but in an altered clinical context so as to maintain the perception of new cases. Each POST phase scenario wasallowed to run up to 7 minutes or until all critical tasks wereperformed, whichever occurred first. Within each phase, scenarios were presented in a random order. During PRE and POSTphases, the sessions were video-recorded. All 3 phases wereperformed in immediate succession, and total time to complete astudy session was 90 minutes. All sessions at all 3 sites wereconducted by the same investigator (A.J.D.) to assure uniformityof the educational experience.For the intervention group, all 3 study phases wereconducted using a high-fidelity infant patient simulator (SimBaby, Laerdal) connected to an air compressor and with audio140speakers enabled, which provided physical signs that werevisible (chest wall movement and cyanosis), audible (vocalsounds), auscultatable (breath and heart sounds), or palpable(central and peripheral pulses). For the control group, thesimulator was disconnected from the air compressor and theaudio speakers were silenced, thus rendering the simulatorequivalent to a standard mannequin. For all study participants inboth groups, scenarios were run using the simulator softwareand evolving vital signs were displayed in real time on a cardiorespiratory monitor interface. All sessions were videorecorded by 2 simultaneous webcam feeds, one of which wassynchronized to the simulator event log and debriefing software(SimBaby Debrief Viewer, Laerdal). During the instructionalsession (second phase), the simulator remained operational so asto demonstrate physical findings pertinent to the PALSalgorithms being reviewed.A scoring instrument (Fig. 2) was designed by investigatorconsensus that granted a maximum score of 2 points for eachcritical task. Points could be deducted if tasks were doneincorrectly, in the wrong sequence, or after an unacceptableamount of time had elapsed. A task was scored 0 points if it was* 2009 Lippincott Williams & WilkinsCopyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care&Volume 25, Number 3, March 2009Effect of High-Fidelity Simulation on PALSFIGURE 2. Sample scoring instrument (for asystole scenario).completely omitted or was performed at a time point where itsimpact on the initial state of the scenario was no longer present(eg, assessing perfusion for the first time after IV fluidresuscitation). This scoring system was adapted from a systemused in a recently published article examining performance inneonatal resuscitation.11 Specific items were chosen according toassessments, and interventions included in PALS algorithms andscores were determined by expert consensus opinion by pediatricemergency medicine and critical care medicineYtrained faculty.For each subject, the video-recorded scenarios during PRE andPOST phases were reviewed, and a summary score for bothphases was generated using this instrument and expressed as apercentage of the maximum possible points (0Y100).Descriptive statistics consisting of score distribution foreach task were performed across both groups. Univariate analyses between SIM and MAN groups with respect to baselinecharacteristics, scores for PRE and POST phases, were doneusing Wilcoxon rank sum testing. Univariate analyses betweenSIM and MAN groups with respect to score distribution forindividual tasks were done by W2 testing for both PRE and POSTphases. Univariate analyses were performed using STATAversion 8.0, Corp, College, Tex.The improvement in score between the PRE and POSTphases was analyzed as our outcome of interest. Mixed modeling with the rescaled scores as the responses, and phases andstudy groups as independent variables, was used with a randomintercept to account for the within-subject covariance. The difference between the 2 groups in improvement from PRE toPOST was assessed by including an interaction term betweenthe study phases and group assignments in the model. Theanalysis was done using PROC MIXED in SAS Institute, Cary,NC version 9.0.RESULTSFifty-one subjects completed all 3 study phases (SIM:n 25, MAN: n 26). Twenty subjects were in postgraduateyear 1 (SIM: n 10, MAN: n 10), and 31 were in postgraduateyear 2 (SIM: n 15, MAN: n 16). Table 1 summarizes thebaseline prior experience of both groups. No significant differences in baseline resuscitation, procedural, or mock codeexperience were present between SIM and MAN groups.Mean scores for PRE and POST phases and the change inscore are listed in Table 2. The PRE phase scores were similarfor both groups. The POST phase scores were higher in the SIMTABLE 1. Comparison of Background of Study GroupsSIM GroupMAN Group1 (0Y12)3 (0Y21)1 (0Y19)4 (0Y12)4 (0Y20)3 (0Y20)0 (0Y10)0 (0)0 (0Y4)4 (0Y25)3 (0Y20)0 (0Y10)0 (0Y2)0 (0Y1)5 (0Y14)2 (0Y10)5 (0Y18)2 (0Y10)Patient eventsResuscitations (nonneonates)Neonatal resuscitationsCritical proceduresBag-valve mask ventilationEndotracheal intubationChest compressionsDefibrillationInterosseous accessTraining eventsMock codesSIM exercisesAll values listed as median (range).* 2009 Lippincott Williams & WilkinsCopyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.141
Pediatric Emergency CareDonoghue et alTABLE 2. Overall Scores (by Group)Phase 1 score, mean (SD)Phase 3 score, mean (SD)Change in score, mean (SD)SIMMANP49.5 (10.7)60.5 (9.1)11.1 (1.8)51.0 (8.8)55.1 (10.4)4.8 (1.7)0.56*0.14*0.007†*Univariate analysis, Wilcoxon rank-sum.†Analysis by mixed modeling, PROC Mixed.group compared with the MAN group, but the difference didnot achieve statistical significance. The improvement in scorebetween PRE and POST phases was significantly greater in theSIM group (11.1 [1.8] vs. 4.7 [1.7], P 0.007).DISCUSSIONThe addition of high-fidelity simulation features to aneducational session given to pediatric residents resulted in agreater increase in scores on an instrument measuring cognitivetask performance. The educational session resulted in increasedscores for both groups, but the increase was significantly greaterin the SIM group.Our results suggest that residents experiencing highfidelity simulation perform cognitive and decision-makingtasks more accurately than those using less realistic models.We believe that some of this improved performance results fromthe more active role that is required from the participant. For theSIM group, their focus is completely on the assessment andinterpretation of vital signs followed by an intervention. Usingthe standard mannequin, the resident must interrupt this criticaltriad by asking questions of the facilitator, making their rolemore passive in interaction.The use of high-fidelity simulation in medicine has beensuggested as a useful teaching method for clinical situations that,although infrequent, are critical in nature and require the maintenance of a high level of skill and preparedness. In this regard,pediatric resuscitation is very well suited to simulationeducation, given that actual pediatric codes are more infrequentthan similar events in adult patients and that outcomes frompediatric cardiopulmonary arrest in both the prehospital andinpatient arenas are poor.12Y14 In addition, pediatric codes tendto be managed in many cases by trained subspecialists when theydo occur, potentially resulting in trainees being marginalized andreceiving less direct resuscitation experience. Current PALSinstruction frequently makes use of partial task trainers forprocedural skill training and standard mannequins for caseexercises, but the use of simulators is less frequent.Studies in pediatric simulation have begun to emerge inrecent years in a variety of clinical venues and with varyingoutcomes of interest under study. Halamek et al10 published theresults of a neonatal resuscitation training program includingsimulation-based experiences and video debriefing that wasrated by participants as highly realistic and effective. Hunt et al7used simulated pediatric trauma patients in unannounced mockresuscitations to assess gaps in preparedness at 35 emergencydepartments in North Carolina and also found a high level ofpositive response from participants. Of note, these studiesused standard mannequins as the patient, and in the case of theHalamek article, a notable difference was present in survey responses regarding the realism of the experience using themannequin, with 50% of respondents not agreeing that themannequin itself was not consistent with a real-life patient142&Volume 25, Number 3, March 2009experience. To our knowledge, our study is the first report of anexperimental study design in pediatric resuscitation educationspecifically examining the effects of high-fidelity simulationfeatures of a patient’s physical signs, as distinct from simply asimulated environment or vital signs.The most recent set of recommendations for resuscitationtraining from the International Liaison Committee on Resuscitation included the specific recommendations that training shouldmove toward Bscenario-based, facilitated, interactive teaching[and that Bhigh-fidelity simulation-directed training should increasingly supplement instructor-directed training[ in Advanced LifeSupport courses.15 Experimental studies examining the effect of asimulation modality on trainee learning in mock adult resuscitations have begun to emerge. Lee et al6 demonstrated a beneficialeffect on performance by surgical residents in a mock traumaresuscitation training session when conducted using a high-fidelitysimulator as opposed to a moulage patient actor. Wayne et al4conducted a crossover study in internal medicine residents wherethe inclusion of simulator practice sessions in Advanced CardiacLife Support algorithms was shown to improve performance on aninstrument measuring cognitive task performance. In a 3-armedrandomized trial comparing high-fidelity simulation to mannequintrainings and to computer-based microsimulation training, Owenet al5 showed that trainee medical officers had improved cognitiveperformance and were rated more highly by expert evaluatorsabout their behavior as code team leaders when trained on a highfidelity simulator. Although all of these studies suggest a benefitfrom the use of a higher level of fidelity in the simulated patient, asour own results also suggest, they are illustrative of the continuedinconsistency in study design and outcome measurement that isprevalent throughout simulation research.LimitationsWe studied the performance of individual residents runningmock resuscitations in an unassisted manner. We chose to studyindividual as opposed to team performance so as to isolate the effect of a one-on-one educational intervention and to use the availability of trained assistants at the bedside to maintain enoughrealism to allow the subjects to function as code team leaders. Participants were told that the setting would be somewhat unrealisticin so far as a team of caretakers would not be physically present.This incomplete realism is not in perfect keeping with the goal ofsuspension of disbelief a simulation exercise is meant to achieve.The most recent revision of PALS guidelines has intensified thefocus on effective resuscitation team dynamics, and the currentPALS course is designed to allow participants to practice the roleof a code team leader in addition to other roles within the codeteam and to rehearse the specific concepts pertinent to teamcommunication and decision making. Studies in mock adultresuscitations have been published, documenting the effect ofsimulation on team performance and crisis resource managementas separate entities from end points pertaining to knowledge orclinical skill.8,9 As simulation research in resuscitation continuesto expand, it will be necessary to design and validate instrumentsto measure team and individual performances to be used asreproducible outcomes of interest for future studies.Our scoring system was designed by investigator consensusand was designed to account for whether tasks were performed,in addition to whether they were done quickly, correctly, and inthe right sequence. We also attempted to account for certainerrors of commission (eg, defibrillation for asystole/pulselesselectrical activity). Our instrument is limited in its scope toexamine cognitive performance and not psychomotor skill. Inaddition, the items are not designed to account for their specific* 2009 Lippincott Williams & WilkinsCopyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care&Volume 25, Number 3, March 2009Effect of High-Fidelity Simulation on PALSclinical impact if done improperly. We believe that using concrete definitions based on PALS algorithms with respect to performing basic assessments and the sequence of assessments andinterventions contributes to face validity of the instrument;furthermore, both groups performed better in the POST phasethan in the PRE phase after one-on-one teaching sessions withan attending, which speaks to some degree of construct validity.The future goal with our current data se
resuscitations designed to teach and reinforce Pediatric Advanced Life Support (PALS) algorithms. Methods: Pediatric residents were randomized to high-fidelity simulation (SIM) or standard mannequin (MAN) groups. Each subject completed 3 study phases: (1) mock code exercises (asystole, tachydysrhythmia, respiratory arrest, and shock) to assess .
Simulation Fidelity to the Digital Twin Applying Levels of Process Model Fidelity Applying the correct level of process model fidelity can be difficult with an incorrect approach resulting in wasted time and money. On one hand, specifications often dictate a high fidelity model while neglecting the requirements of dynamics and real-time response.
§ High-Fidelity Prototypes (Mockup & Software Prototype) § Analysed the number of style properties of a button across different fidelity levels (Sketch: 7 à Mockup: 37 à Product: 71) Fidelity Speed Cost Navigation Interactivity Responsivene Style Information Low-Fidelity Protot
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simulation for Mars rover is needless because it cannot take continuous tele-operation mode due to the large time delay. So that comprehensive virtual simulation system that can switch between high-fidelity and high-speed simulation for lunar rover is necessary to be developed. This pape
HIP Program Fidelity Fidelity is defined by Webster as "the quality or state of being faithful, the accuracy in details, exactness." Program fidelity assessment offers another level of detail about the program as implemented by examining the degree to which interventions are implemented as theoretically planned. -Poor Fidelity .
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