Improving Care for PediatricsNancy M. Tofil, M.D., M.Ed.

October 2011

Disclosure

• I have no conflict of interests to disclose

Overview

0-5min Introduction/Turning Point Slides5-15min Objectives15-45min Review Pediatric courses and

opportunities45-60min TAPPS – List barriers and discuss

strategies to overcome to overcome the barriers

60-75min Wrap-up / Top 10

How long have you been involved in simulation?

0-6month

s

6-12mont

hs

12-18months

18-24months

2-5years

>5years

17% 17% 17%17%17%17%

1. 0-6months2. 6-12months3. 12-18 months4. 18-24 months5. 2-5 years6. > 5years

What is your role?

Simulat

ion te

c...

Nurse ed

ucator

Physici

an/ A

dv...

Administrat

or

Other

20% 20% 20%20%20%

1. Simulation technologist2. Nurse educator3. Physician/ Advanced

provider4. Administrator5. Other

Who is your primary learner?

Nurse

Med

ical S

tuden...

Residen

ts

Staff P

hysici

a...

EMT O

ther

17% 17% 17%17%17%17%

1. Nurse2. Medical Student3. Resident4. Staff Physician5. EMT6. Other

Where is your center located?

Free st

anding

In hosp

ital

In nursi

ng or ...

In m

edica

l sch

...

Other

20% 20% 20%20%20%1. Free standing2. In hospital3. In nursing or allied health

school4. In medical school5. Other

Which high-fidelity pediatric simulators do you have?

Laerd

al

METI

Gau

mard

More

than one .

..

25% 25%25%25%

1. Laerdal SimBaby2. Laerdal SimNewB3. METI Child4. Gaumard 5. More than one type6. None yet

What do you feel is the biggest obstacle you face concerning moving simulation

forward at your institution?

1. Financial related2. Technical knowledge3. Time constraints4. Hospital support

What is your primary goal from this workshop?

1. Programming Advice2. Ideas for pediatric sim

courses3. Strategies to move your

center ahead4. Product advice5. Obtain new scenarios6. Other

Learning Objectives

1. Discuss the medical/legal environment in the pediatrics area

2. Identify issues specific to pediatric care3. Describe the history of pediatric simulation4. Describe the role of simulation in providing

quality pediatric education5. Discuss collaboration with multidisciplinary

leadership6. Describe how to plan and implement pediatric

simulation7. Define measurable objectives for success

Medical/Legal Environment

1. Patient safety2. Resident duty hours3. Transition of responsibility to fellows and

attendings4. Nursing students less exposure5. New nurses less skilled

Issues Specific to Pediatrics

• Multiple sizes• Multiple normal values

– Vital Signs– Laboratory Values– Radiograph findings

• Many patients unable to explain their concerns• Interaction of care givers• Social concerns• Kids are never supposed to die

History of Pediatric Simulation

• Laerdal SimBaby – released 2005• Laerdal SimNewB – released 2009• METI Child – released 2006• Gaumard HAL – released early 2000’s• Laerdal SimChild - soon• Always behind adult technology• Never will have as much potential profit

Role of Simulation in Providing Quality Pediatric Education

First Year Second Year

Third Year Fourth Year

0

2

4

6

8

10

12

OldNewYears after professional degree

Hou

rs o

f exp

erie

nce

(in

thou

sand

s)1. Clinical

Education Inefficient2. No Debriefing3. No scheduled

admissions

Role of Simulation in Providing Quality Pediatric Education

• John Dewey, “All genuine education comes about through experience but not all experience educates and some experience mis-educates”

• Experience is the backbone of adult learning theory

Kolb’s Experiential Learning Cycle*

ConcreteExperience

ReflectiveObservation

Abstract conceptualization

Active experimentation

Debriefing

Relating to actual situations, developing rules, algorithms

Practicing

*Kurt Lewen

Simulation

1.Standardize exposure2.Scheduled debriefing

• Began August 2007• 8 Mannequins • 3 Simulation rooms• Conference room• Audiovisual capability

in all rooms• Storage

Children’s of Alabama Pediatric Simulation Center

15,000 learners

• SimBaby x2• SimNewB• SimMan• SimMan Essential• METI PediaSim• Gaumard Pediatric

Hal 1 Year• Gaumard Pediatric

Hal 5 Year

Our Mannequins

1. Radiology (Attending and Technologist)2. ECMO (ECMO Team)3. PICU (Physician, Nurse and Pharmacy)4. Mock Code (Code Team)5. Trauma (Trauma Team)6. Death and Dying (Physician, Nurse, Social Work and

Chaplain)7. Forensic Evidence (Physician, Nurse)8. Medical Student Clerkship (Medical, Nursing and

Pharmacy Students) 9. Sedation (Physician, Nurse, Technologist)10. Cardiovascular (Physician, Nurse Practitioner, Nurse)

Multidisciplinary Courses

ECMO

PICU

Mock Code

Trauma

Death and Dying

Forensics – Sexual Abuse Evidence Collection

1. Orthopedics2. Anesthesia and CRNA3. Pharmacy Student4. PICU Nursing5. Solid Organ Transplant Nursing6. Dialysis Nursing7. NICU Nursing

“Silo” Courses

Orthopedics

Anesthesia and CRNA

NICU Nursing

1. Nursing Skills Labs (First 5 Minutes of a Code)2. PALS3. Geriatrics4. NRP5. Clinical Assistant6. New Hire Nursing Assessment7. Sleep Technologists8. Nursing Mock Code Orientation9. Home Ventilator10. Teen Trauma Prevention 11. Medication Errors

Specialty Courses

Geriatrics

Home Ventilator Simulation for Parents

• Tracheostomy• Intubation• Basic Airway• Surgical Airway• Crisis Resource Management • Intern Skills• ENT Foreign Body Removal

Workshops

Basic & Advanced Airway

ENT Foreign Body Retrieval

Intern Skills

• Request comes in or need identified• Face to face meeting• Content expert identified• Learners identified• Goals and objectives • What simulation can and cannot do• Specific cases discussed

Where to begin

IDEAS FOR CASES1. Sentinel events2. Near misses 3. Rare events (contrast reactions) 4. Safety & equipment issues5. Requests6. Codes7. Premature Closure8. Hand offs

• Who? Learners, content expert, simulation staff• What? Objectives, take away points• When? Frequency• Where? Simulation Center, in situ, somewhere else• Why? Change in knowledge, skills, attitudes• How? Moulage, labs, xrays, equipment

Process

RESOURCES1. Online: forms, scenarios, programming, moulage2. Internal: staff3. Networking4. Organizations5. List serves

• Moulage• Family members• Xrays, labs, ECG• Clothes, wigs, toys,

eyeglasses• Voices• Use real equipment (no

pretending)• Unusual distracters (impaired

clinician, family issues)

Make It Interesting

Moulage

Accessorize

Evaluation: Generic

I am a • MD • RN• Resp Therapy • Pharmacist• Radiology Tech• Nursing Student• Medical Student• Chaplain• Social Work• Other_______

Agree Neither Agreenor Disagree

Disagree

I found to be valuable learning experience.

Debriefing and group discussion were valuable learning Experiences.

I will be able to apply what I have learned in my work position/job.

I was challenged in my thinking and decision-making skills.

I developed a better understanding of the management of pediatric disorders/emergencies.

This experience has increased my confidence level in pediatric disorders/emergencies

This experience has increased my skill level in pediatric disorders/emergencies.

I feel better prepared to care for real pediatric patients.

I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient.

I would recommend this program to others.

The Instructor(s) was knowledgeable about the subject(s) presented.

My personal objectives for this course were met.

Evaluation

1. Do you feel your participation in this course will improve your performance as you encounter medical complications in the actual clinic setting? 

2. Two things I liked/learned today: a) b)

3. Two things I wish we had focused on or that could be improved: a) b)

Comment/Suggestions/Recommendations:

TAPPS

• TAPPS – Think Aloud Paired Problem Solving1

• Active Learning Technique• Pair up• Discuss proposed problem• As instructor state, “We will do this exercise for

___ minutes. I will give you a 1 min heads up. At the completion of the exercise I will call on some groups to share their thoughts. Does anyone have any questions before we get started.”

1. Harvey Brighton

Top 10 Things that Helped our Simulation Center to Succeed

10. Simulator Voice– 10W Guitar Amp ($60)– RadioShack 170 MHZ wireless lapel

microphone ($50)– 72inch LPM cable ($5)

PRICELESS

Top 10

9. Caregiver (parent, spouse, child)– Hospital volunteer– Medical student

Top 10

8. Free/ Nearly Free Supplies– X-rays – Laboratory reports– Costumes (thrift stores)– Trash bins (Stroller, IV pumps) – Expired medical supplies

Top 10

7. Short scenarios (10-15min) and long debriefings (20-45min)

– Start with scenarios you feel most comfortable with and expand from there

– Same stem for multiple learners – make it more gray for more advanced learners

• JW, F8 def– Change rhythms

Top 10

6. The Basic Assumption

Everyone participating in activities at the Children’s Hospital Pediatric Simulation Center is intelligent, well-

trained and dedicated to improve their care for children.1

1. Adapted from Center for Medical Simulation, Boston MA

Top 10

5. Relatively simple video system

– Video-switcher • Picture in Picture

– Apple – I Movie

Top 10

4. Weekly simulation team meetings– Keeps everyone accountable to each other

Top 10

3. Make friends – High and Low Places– Housecleaning– Pharmacy – Engineering– Security– Hospital volunteers– Hospital CEO

Top 10

2. Candy!!– Everyone learns more when fed!!

Top 10

1. Have fun and keep it simple

Celebrate Success

I hear and I forgetI see and I rememberI do and I understand

Confucius, 551-479 BC