Improvement U – Arkansas Children’s Hospital, Little Rock, AR

Methods

Adult Mock Codes for Pediatric Residents: An ACLS RefresherTaylor Bagwell M.D., Elizabeth Storm M.D., Kim Nelson, Lee Crawley MS RRT-NPS, Tonya Thompson M.D.

Introduction Outcomes

Barriers and Lessons Learned

SMART Goal

Measures

Next Steps

• 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. • In our 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.

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.

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

InterventionsTests of Change:• Implementation of mock codes with debriefing• Distribution of learner’s guides prior to mock codes with encouragement of

use during mock codes• Case specific pediatric house staff lectures

• Results:• Overall resident participation averaged 69%.• Regarding chest pain, there was 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, there was 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%.

• 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.

• 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

• 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.

Key Driver Diagram

• Educational interventions made as tests of change via mock codes, cognitive aides, and didactics.

• Mock codes included PED nurses and pharmacists for an Interprofessional Education Experience.

• Six month time blocks devoted to each topic. • Adult chest pain case = acute ST segment elevation myocardial

infarction which deteriorated into ventricular tachycardia. • Adult stroke case = hemorrhagic stroke in hypertensive patient with

associated neurogenic pulmonary edema. • Mock codes facilitated by PED staff with ACLS certification.• Case based learner’s manuals provided and didactic sessions held

during each block. • Participant competence assessed using ACLS guideline based

checklists, with identified key elements, and pre and post experience knowledge based questionnaires.

• Confidence evaluated by pre and post experience scale based survey.