Adult Mock Codes for Pediatric Residents: An ACLS Refresher

Team Members:Taylor Bagwell, MD

Beth Storm, MDKim Nelson

Lee Crawley, MS, RRT-NPSTonya Thompson, MD

Mentor: Doreen Tooch

Background

• Pediatric providers have little experience treating adults.

• Advanced Cardiac Life Support (ACLS) certification is not often required of pediatric providers.

• Pediatric emergency department (PED) staff must stabilize adults prior to transfer to an adult facility.

• Resultant knowledge gaps may negatively impact care.

Background• ACH ED in 2014:• 262 patients over the age of 21 were seen • Chest pain and an acute neurologic change were

the two most common adult presentations

Project Aim

Improve pediatric resident competence and confidence in the assessment and stabilization of both adult chest pain and stroke by 25% over a total of 12 months.

Measurements

Outcome Measure: ACH Resident confidence and competence in the stabilization of acutely ill adult patients with chest pain and stroke.Process Measures:• Pre and post participant surveys- confidence• Facilitator checklist with key items emphasized - competence• Pre and post knowledge based assessment – competence

Interventions• Tests of Change:• Implementation of mock codes with debriefing• Distribution of learners guides prior to mock codes

with encouragement of use during mock codes• Case specific pediatric house staff lectures

Key Driver Diagram

Project Aim

Key Drivers/ Processes

Design ChangesImprove pediatric resident competence and confidence in the assessment and stabilization of both adult chest pain and stroke by 25% over a total of 12 months.

Opportunity: Pediatric providers need dedicated time allotted for continued training in adult care.Education: Pediatric providers need continued education regarding adult care. Experience: Pediatric providers need increased experience in providing adult care.

Evaluation/Feedback: Pediatric providers need to receive feedback and guidance regarding adult care.

• Capture all eligible participants• Arrange dedicated time for learning

about adult care

• Case specific learner’s guides• Case specific didactics

Adult chest pain and stroke mock codes • Pre and post scenario surveys• Pre and post scenario knowledge

based assessment• Observer/Facilitator checklist• Post scenario debriefing/feedback

ACH Resident confidence and competence in the stabilization of acutely ill adult patients with chest pain and stroke (as determined by self report and observer scoring).

Measure

Results• Results:– Overall resident participation averaged 69%• Regarding chest pain, residents demonstrated a 34%

increase in confidence and a 41% knowledge increase. Adherence to the complete checklist increased by 10%. Adherence to key elements increased by 8%.

• Regarding stroke, residents demonstrated a 46% increase in confidence and a 30% knowledge increase. Adherence to the complete checklist increased by 12%. Adherence to key elements increased by 15%.

Chest Pain Confidence & Knowledge1. Today’s Date

2. I am a Med/Peds resident (circle one):

Other: ___________________________________________________________

3. Did you read the teaching guide? No Yes

1= Not Confident at All 2= Somewhat Confident 3= Confident4= Very Confident

1Not

Confident At All

2Somewh

at Confide

nt

3Confide

nt

4Very

Confident

4. I am confident I can perform an assessment on an adult with chest pain

5. I am confident I can administer medications at the correct dosages to an adult patient with chest pain

6. I am confident I can perform proper CPR on an adult

7. I am confident I can recognize a STEMI in an adult patient

8. I am confident I can correctly defibrillate an adult patient

9. I am confident I can treat an adult chest pain patient without causing harm

10.

I am confident I can give timely and proper information to the adult receiving facility for an adult patient with a STEMI

11.

How far do you depress the chest in Adult CPR (insert answer in the box to the right)?

12.

What is the initial energy voltage set for an adult patient with unstable Ventricular Tachycardia (insert answer in the box to the right)?

13.

What is the target O2 saturation for an adult chest pain patient after a return of spontaneous circulation?

14.

Name a medication specific contraindication to giving nitrates in adult chest pain patients.

15.

What drug is indicated for shock resistant VT in adults

41% Average increase in knowledge from pre to post

34% Average increase in confidence from pre to post Assessment

Chest Pain Knowledge Based Assessment

2/3/2015 3/3/2015 3/17/2015 3/26/2015 4/21/2015 4/30/2015 5/5/2015 5/19/2015 5/28/2015 6/2/20150%

20%

40%

60%

80%

100%

120%

Pre and Post Knowledge Assessment

Pre Correct Post Correct Difference

41% average

increase in knowledge

Chest Pain Checklist Results

2 = Done Well1 = Attempted0 = Not DoneThese scores are averaged from checklists

Complete Checklist Key Item Checklist

3-Feb 3-Mar 17-Mar 26-Mar 21-Apr 30-Apr 5-May 19-May 28-May 2-Jun

1.21 1.41 1.47 1.34 1.67 1.55 1.48 1.48 1.64 1.48

1.60 1.70 1.90 1.70 1.60 1.80 1.80 1.80 2.00 2.00

Complete

Key Item

March 17th – Encouraged use of cognitive aidsApril 21st – First course following an unfortunate cardiac event

Desired Direction

73% Average Adherence 89% Average Adherence

3-Feb3-Mar17-Mar26-Mar21-Apr30-Apr5-May19-May28-May2-Jun15-Sep1-Dec

0.000.200.400.600.801.001.201.401.601.802.00

1.21

1.41 1.47 1.34

1.671.55 1.48 1.48

1.641.48 1.49

1.64

0.000.200.400.600.801.001.201.401.601.802.00

1.601.70

1.90

1.701.60

1.80 1.80 1.802.00 2.00

1.57

1.80

Averages

Median

Stroke Confidence & Knowledge1. Today’s Date: Symbol:

1= Not Confident at All 2= Somewhat Confident 3= Confident4= Very Confident

1Not

Confident At All

2Somewhat Confident

3Confident

4Very

Confident

2. I am confident I can identify adult patients with possible stroke. 3. I am confident I can assess possible stroke patients using standardized

abbreviated stroke scales.

4. I am confident I can manage vital sign abnormalities appropriately in an adult patient with suspected stroke.

5. I am confident I can administer the proper medications/dosages of medications to an adult patient with suspected stroke.

6. I am confident I can appropriately transfer adult patients with stroke like symptoms to facilities capable of caring for them.

7. I am confident I can give timely and proper information to the adult receiving facility for an adult patient with a suspected stroke.

8. I am confident I can treat an adult with stroke like symptoms without causing harm.

9.

What are the elements of the Cincinnati Prehospital Stroke Scale?

10.

Why is the last known well time important?

11. Why is checking glucose important in adult stroke patients?

12. Name three contraindications to giving fibrinolytics in adult stroke patients.

13. What is important to remember about hypertension in adult stroke patients?

14.

This simulation was helpful in enhancing my confidence in treating Adults with stroke like symptoms (circle one)

1Not At All

2Somewhat

3Helpful

4Very Helpful

15. Will you change the way you treat an Adult patient with stroke like symptoms for the better due to something you learned in this simulation

No Yes

16. Suggestions for improvement:

30% Average increase in knowledge from pre to post Assessment

46% Average increase in confidence from pre to post Assessment

97% of participants stated he/she would change the way he/she treated an adult patient with stroke like symptoms for the better due to something you learned in this simulation?

Stroke Knowledge Based Assessment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre and Post Knowledge Assessment

Pre Post Difference

30% average

increase in knowledge

Stroke Checklist Results

7/21/2

015

7/30/2

015

8/4/2

015

8/18/2

015

8/27/2

015

9/1/2

015

10/6/2

015

10/20/2

015

10/29/2

015

11/3/2

015

11/17/2

015

12/15/2

0150

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1.39

0.77

1.39

1.27

1.41

1.34090909090909

1.38636363636364

1.51.39

1.77

1.36

1.64

Complete Checklist

2 = Done Well1 = Attempted0 = Not DoneThese scores are averaged from the checklists

7/21/2015

7/30/2015

8/4/2

015

8/18/2

015

8/27/2

015

9/1/2

015

10/6/2

015

10/20/2

015

10/29/2

015

11/3/2

015

11/17/2

015

12/15/2

0150.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

1.71

0.86

1.29

1.27

1.71

1.57 1.50

1.791.86 1.86

1.57 1.57

Key Item Checklist

Desired Direction

Averages

Median

October 6th – Encouraged use of cognitive aids

21-Jul 30-Jul 4-Aug 18-Aug 27-Aug 1-Sep 6-Oct 20-Oct 29-Oct 3-Nov 17-Nov 15-Dec

Complete 1.39 0.77 1.39 1.27 1.41 1.34 1.39 1.5 1.39 1.77 1.36 1.64

Key 1.71 0.86 1.29 1.27 1.71 1.57 1.5 1.79 1.86 1.86 1.57 1.57

73% Average Adherence

78.5% Average Adherence

Conclusions• Conclusions:• Limitations exist in the pediatric care provider’s

assessment and stabilization of acutely ill adults. • Knowledge gaps are amendable to educational

intervention.• Participation in simulation based mock codes is

beneficial. • Use of cognitive aides and didactic sessions

appear to enhance performance.

Barriers and Lessons Learned• Loss of eligible participants:• Course cancellation – weather, unavoidable

events/conflicts• No shows – chief residents arranged make up mock

codes• Participant and facilitator by in affects quality of

experience• Standardization of simulation experience necessary• Standardization of facilitator training, expectations,

and scoring systems necessary

Next Steps• Continue developed educational process and

expand to other areas of identified weakness.• Implement retention mock codes on

previously covered topic for maintenance of competence/confidence.

The End

Thank you!

Questions?