The Journal of Continuing Education in Nursing

Original Article 

Improving Adherence to a Pediatric Advanced Life Support Supraventricular Tachycardia Algorithm in Community Emergency Departments Following in Situ Simulation

Riad Lutfi, MD, FAAP; Erin E. Montgomery, RN; Zachary J. Berrens, MD; Mouhammad Yabrodi, MD; Mathew L. Yuknis, MD; Michele L. Kirby, RN; Kellie J. Pearson, RRT; Samer Abu-Sultaneh, MD; Kamal Abulebda, MD

Abstract

Background:

Recognition and management of pediatric dysrhythmias is challenging for community emergency department (CED) providers, given their infrequent exposure to these cases.

Method:

A prospective, interventional study measured adherence of CEDs to pediatric supraventricular tachycardia (SVT) algorithm pre- and postimplementation of an in situ simulation-based collaborative program. CED teams' adherence was scored using a composite adherence score (CAS) based on the number of actions scored correctly on the performance checklist.

Results:

A total of 74 multiprofessional teams from nine CEDs participated in simulated sessions. Of 367 participants, 12.3% were physicians, 62.1% were RNs, and 25.6% were other providers. The mean CAS improved from 57% to 71%. The ability to identify an SVT rhythm, stable versus unstable SVT, and the correct performance of synchronized cardioversion significantly improved.

Conclusion:

This study demonstrated improvement in overall adherence of CEDs to pediatric SVT algorithm following a collaborative program in simulated setting. This approach could be adapted to improve the quality of care provided to children. [J Contin Educ Nurs. 2019;50(9):404–410.]

Abstract

Background:

Recognition and management of pediatric dysrhythmias is challenging for community emergency department (CED) providers, given their infrequent exposure to these cases.

Method:

A prospective, interventional study measured adherence of CEDs to pediatric supraventricular tachycardia (SVT) algorithm pre- and postimplementation of an in situ simulation-based collaborative program. CED teams' adherence was scored using a composite adherence score (CAS) based on the number of actions scored correctly on the performance checklist.

Results:

A total of 74 multiprofessional teams from nine CEDs participated in simulated sessions. Of 367 participants, 12.3% were physicians, 62.1% were RNs, and 25.6% were other providers. The mean CAS improved from 57% to 71%. The ability to identify an SVT rhythm, stable versus unstable SVT, and the correct performance of synchronized cardioversion significantly improved.

Conclusion:

This study demonstrated improvement in overall adherence of CEDs to pediatric SVT algorithm following a collaborative program in simulated setting. This approach could be adapted to improve the quality of care provided to children. [J Contin Educ Nurs. 2019;50(9):404–410.]

Pediatric cardiac dysrhythmias can present in a spectrum of clinical scenarios: they can be completely asymptomatic, present with nonspecific symptoms, and present with cardiovascular collapse or even sudden death. Supraventricular tachycardia (SVT) is the most common form of symptomatic tachydysrhythmia encountered in pediatric patients (Atkins et al., 2018; Clausen, Theophilos, Jackno, & Babl, 2012).

Most children with acute emergencies, including those with SVT, are initially cared for at the nearest emergency department (ED). This is often a community emergency department (CED) that cares for both children and adults. Most of these CEDs care for fewer than 15 pediatric patients per day (Whitfill et al., 2018). In addition to infrequent exposure to acutely ill children, a national survey found that CEDs have limited access to pediatric-specific policies and guidelines, making them less prepared to care for children (Abulebda, Lufti, et al., 2018; Gausche-Hill et al., 2015; Whitfill, Gawel, & Auerbach, 2018).

Adherence to the current American Heart Association (AHA) life support guidelines has been associated with improved survival (Sutton et al., 2014). Despite this, studies have demonstrated poor adherence of CEDs to adult AHA guidelines. Recently, a large multicenter study demonstrated lower adherence to basic life support guidelines in lower volume CEDs, compared with higher volume CEDs (Auerbach et al., 2018).

Historically, the AHA has advocated resuscitation training course recertification, such as Pediatric Advance Life Support (PALS), every 2 years. However, there is growing evidence of a significant loss of skills and knowledge retention 6 to 12 months following the PALS course (Sutton et al., 2011). Pediatric patients who present with SVT are at a particular risk given the low frequency of use of antidysrhythmic medications and cardioversion in CEDs, which poses a greater challenge for staff training and skills retention (Clausen et al., 2012). An alternative approach is needed to ensure the readiness of CEDs to treat pediatric SVT.

Simulation is a powerful assessment tool that can be used to detect opportunities to improve quality of care and identify safety threats in the ED setting (Patterson, Geis, Falcone, LeMaster, & Wears, 2013). Simulation-based appraisal provides a robust measurement of patient care and adherence to existing guidelines (Brydges, Hatala, Zendejas, Erwin, & Cook, 2015). Simulation provides a platform for trained educator teams to measure the quality of care delivered by multiprofessional health care teams (Cheng, Auerbach, et al., 2014). There is a growing body of evidence supporting the use of simulation to measure and improve the quality of care in clinical settings (Patterson et al., 2013).

The purpose of this study was to assess and improve the adherence to the PALS SVT algorithm across a spectrum of CEDs in a simulated setting. We hypothesized that a collaborative educational improvement program between the academic medical center (AMC) and the CEDs using in situ simulation will improve adherence to the PALS SVT algorithm.

Materials and Method

Study Design

This was a prospective, pre- and postinterventional study lead by an AMC to measure and improve the performance of CED clinical teams' management of pediatric SVT in a simulated setting. This study was approved by the institutional review board.

The goals and objectives of this study were developed to address the key points of identification and management of SVT. These key points were determined by a group of pediatric intensivists, pediatric emergency physicians, and pediatric critical care transport providers based on their own professional experience and in light of the clinical responsibilities that they expected the CED teams to perform. Furthermore, pediatric educators from three CEDs reviewed the learning objectives to ensure relevance to their CED teams. Learning objectives were developed to build knowledge, improve skills, and enhance teamwork among these providers (Table 1). These clearly defined objectives subsequently guided simulation scenario and performance checklist development in order to create a specific, measurable, and valid assessment tool. The scenario was then pilot tested with a subgroup of the expert panel to ensure content and face validity prior to implementation.

Learning Objectives

Table 1:

Learning Objectives

The study was conducted between May 2016 and August 2017 in nine of 121 CEDs in Indiana that deliver care to children. All site visits were scheduled in coordination with each hospital's CED educator or manager. CED teams were recruited to participate in the simulation sessions by study coordinators through each CED manager or director who served as a “pediatric champion” for their site. A collaborative educator team named the Pediatric Community Outreach Mobile Education from the pediatric AMC led the study. The educator team included three pediatric intensivists, two critical care transport RNs, and a critical care transport respiratory therapist. All educators had experience in simulation and postsimulation debriefing and had completed a simulation training course prior to the study. The CED teams were composed mainly of RNs, respiratory therapists, emergency physicians, and physician assistants. Pharmacists and emergency medical technicians were also included if available, given that they were a part of the resuscitation team. CED team size was limited to five providers per simulation scenario to reflect actual clinical practice. All providers were protected from clinical duties during the simulation sessions. To encourage participation, continuing education credits were offered free of charge.

Study Protocol

The theoretical framework of this study was based on Kolb's educational theory of experiential learning (Kolb, 1984). Kolb's framework includes four phases: concrete experience, reflective observation, abstract conceptualization, and active experimentation. In this context, the initial simulation event serves as the concrete experience. The debriefing immediately following provided the chance for learners to undergo reflection and conceptualization. Finally, the learners critically reviewed their performance and developed a plan of action for future experimental exploration in the simulated or clinical setting.

The project consisted of three phases: (a) baseline, in situ assessments, (b) targeted system-wide interventions, and (c) postintervention improvement assessments (Figure 1).

Project phases.

Figure 1.

Project phases.

Baseline in Situ Simulation. All in situ simulations began with a presentation to introduce the educator team and provide the participants with the expectations for the simulation sessions. Prior to each simulation session, participants were oriented to the functionality of the simulator. Simulation sessions took place in each facility's CED rooms using each site's actual equipment (e.g., infusion pumps, defibrillator), supplies (e.g., syringes), resources (e.g., cognitive aids), and policies and guidelines. All CED teams participated in a standardized in situ simulated scenario for an infant presenting with SVT. At the beginning of each scenario, the educator team provided the participating ED team with a brief clinical scenario. Laboratory and imaging data were provided upon request on preprinted laminated cards (e.g., including arterial blood gas, glucose, electrolytes, electrocardiogram, and chest radiograph). Each scenario lasted 15 minutes and was followed by a 30-minute constructive debriefing (Table A; available in the online version of this article).

Targeted System-Wide Intervention. Postsimulation Debriefing. Following the in situ simulation, an educator-guided postsession debriefing was conducted. During the debriefing, educators focused on engaging all CED team providers to discuss individual and team performance, identify errors, and develop improvement strategies via a reflective learning process. Educators used the traditional three-phase structure model (reaction, analysis, and summary) for debriefing to maximize the learning experience among participants. Educators ensured that relevant issues and learning objectives were addressed during the debriefing. As an example, if the team used an inappropriate dose or route of adenosine, the educator would provide the opportunity to learners for self-discovery through a reflective question, such as “Was the appropriate adenosine dose/route used?” and “If not, what needs to change to improve it?” In addition, the use of equipment and medications needed during the case was reviewed and emphasized. By the end, all safety threats encountered were highlighted.

Hands-On Practice. CED teams were provided with a 20-minute hands-on practice session to enhance technical skills, such as the appropriate method of adenosine administration and defibrillator use. Team members engaged in these rapid practice sessions to reinforce the relevant learning objectives encountered during the preceding debriefing.

Targeted Assessment Reports. A targeted assessment report identifying deficiencies noted during the simulations was provided to the CED within 2 weeks of the baseline simulation sessions. The assessment report summarized the deviations from best practices, knowledge and performance gaps, and all identified safety threats. This report was presented in person to each CED pediatric champion and served as a guide to empower each CED to review the teams' performance data and independently implement educational improvement strategies. As an example, when a report identified a site missing PALS SVT guidelines and a need for additional defibrillator skills training, the educator team would share the needed guidelines with the CED and recommend the site pediatric champion to offer additional defibrillator training sessions for their team to optimize their skills.

Access to Resources and Ongoing Communication With AMC Pediatric Experts. The educator team provided the learners with education on key points of pediatric assessment and examination, with a focus on the assessment of perfusion and mental status. Participant teams were provided with age-appropriate educational materials and resources (vital signs tag cards, Broselow Pediatric Emergency Tape, smartphone applications, and PALS cards). Each CED site was also provided with the collaborative team website, which includes best practices, guidelines, algorithms, and high-quality educational modules focusing on the management of acute pediatric illnesses in the CEDs.

Postintervention Improvement Assessment. Six to 8 months following the baseline simulation, the educator team conducted a follow-up assessment of the same CED sites. A follow-up in situ simulation session was performed at these CEDs. All teams participated in a simulated case scenario of an infant with SVT maintaining the same learning objectives with a different patient history (i.e., patient age, weight, and initial presentation were changed, but the same scenario flow and objectives were maintained). The educator team, using the same critical action checklist as in the baseline assessment, scored CED teams in the follow-up assessment visits. Constructive debriefing was performed following each session and teams were given the opportunity to have hands-on practice and use their CED resources.

Outcome Measures

After each simulation, the educator team scored the performance of the participant teams using a 7-item critical actions checklist. The performance measures were developed based on PALS SVT algorithm (Atkins et al., 2018). Performance was scored in real time based on the number of items performed correctly using individual checklists for each scenario by two separate educators who scored each checklist independently. Scores were then discussed between the educators to reach consensus. Each case performance score was calculated using equal weighting for all subcomponents then dividing by the total number of possible elements to derive a score on the scale of 0 to 100 to calculate the Composite Adherence Score (CAS).

Statistical Analysis

Analyses were performed using SAS® version 9.4. Data were examined for normality and homogeneity in each analysis. We examined differences in team performance data by pediatric patient volume and by presence of inpatient pediatric services using bivariate analyses. For these bivariate analyses, we conducted Wilcoxon rank sum tests on the continuous data, and Fisher's exact tests were performed for categorical variables. We tested improvement in simulation checklist scores with Wilcoxon nonparametric tests when comparing groups and Wilcoxon signed rank tests for overall change.

Results

All nine CEDs participated in the baseline visits, the intervention, and the follow-up visits. A total of 34 multiprofessional teams participated in baseline simulation visits and 40 teams in follow-up visits. Twenty percent of the participants from baseline assessment were present in the follow-up assessments. Of the 367 participants, 45 (12.3%) were physicians, 228 (62.1%) RNs, 38 (10.3%) RTs, and 56 (15.3%) other (paramedics, pharmacists, or students). Team characteristics and CED demographics are shown in Table 2. All CED teams demonstrated a significant improvement in overall adherence to PALS SVT algorithm as measured by the critical action checklist. The median CAS increased from 57% at the initial to 70% at the follow-up visit (p = .004). All CED teams showed improvement in five of seven checklist items between both visits (Table 3). CED pediatric patient volume or presence of an inpatient pediatric unit in each CED hospital did not have an effect on CAS improvement (Table 4).

Characteristics of Participating Teams and Hospitals

Table 2:

Characteristics of Participating Teams and Hospitals

Comparison of Adherence to PALS Supraventricular Tachycardia Algorithm Between Baseline and Follow-Up Visits

Table 3:

Comparison of Adherence to PALS Supraventricular Tachycardia Algorithm Between Baseline and Follow-Up Visits

Baseline and Improvement of Supreventrciular Tachycardia Management Based on the Presence of Inpatient Pediatric Units and Community Emergency Department (CED) Pediatric Volume

Table 4:

Baseline and Improvement of Supreventrciular Tachycardia Management Based on the Presence of Inpatient Pediatric Units and Community Emergency Department (CED) Pediatric Volume

Discussion

Our simulation-based educational improvement program resulted in significant improvement in the adherence to PALS SVT algorithms across a spectrum of CEDs statewide. Improvement was noted in crucial components of the SVT algorithm. We believe that a collaborative, in situ simulation program between AMCs and CEDs is a model that could lead to system-wide improvement in these CEDs.

Traditionally, simulation has been used to train health care professionals for high-stakes, low-frequency events and to improve team confidence and performance. Previous studies have shown that simulation is an effective tool to increase technical skills and fund of knowledge in acute care providers (Hunt, Walker, Shaffner, Miller, & Pronovost, 2008). Despite this, there have been concerns about retention of skills and knowledge following simulation. Recent studies showed poor retention of pediatric advanced life support provider skills within several weeks if not applied (Hunt et al., 2008; Kurosawa et al., 2014).

In our study, sustained improvement in adherence to SVT algorithms was noted 6 to 8 months following the baseline assessment across all participating CEDs. This is an important finding, as our education initiative used in situ simulation as a catalyst for CED system improvement rather than the traditional use of simulation for individual and team training. During the baseline assessment, despite 70% of participants being PALS certified, we noted knowledge deficits and practice gaps in recognition and management of SVT among CED teams. Less than 20% of teams were able to recognize a stable SVT from non-stable SVT. Less than 50% were able to perform a correct cardioversion due to poor familiarity with the defibrillator. On the basis of these findings, we developed our systemwide intervention to improve adherence to pediatric SVT algorithm in these CEDs.

A crucial component of our intervention was the post-simulation debriefing. Debriefing has been identified as the most important aspect of health care simulation (Sawyer, Eppich, Brett-Fleegler, Grant, & Cheng, 2016). Debriefing allows for reflective self-assessment and provides means to develop action items for continuous learning to improve individual and team performance (Cheng, Eppich, et al., 2014). Our debriefing was followed by hands-on sessions for all providers. Participants had the opportunity to practice performing cardioversion until they felt confident.

Another aspect of our intervention, beyond postsimulation debriefing, was creating and distributing pediatric educational materials such as vital signs, tag cards, and PALS SVT algorithm sheets. These education materials likely contributed to the performance improvement, as these resources were commonly used during the follow-up visits.

The targeted assessment report was a unique component of the intervention. This report included an overview of team performance and deficiencies noted during the simulations. This document was a supportive tool for CEDs' champions to engage their own leadership to address their CED's unique educational needs and to integrate system-wide changes. These customized reports addressed each individual CED's gaps noted during simulations and urged CED leadership to offer additional refresher training or local educational sessions to enhance their providers' skills and competencies that likely resulted in improved performance in the follow-up simulations.

Our results are consistent with other reports demonstrating the successful use of simulation as a modality of quality improvement research to evaluate processes of care, identify areas needing improvement, and identify system issues (Abulebda, Abu-Sultaneh, et al., 2018; Auerbach et al., 2016; Kessler et al., 2016). Furthermore, recent studies demonstrate the translational outcomes of the simulation-based improvement programs—beginning in the simulation environment, moving to improved patient care practices, and ending with better patient outcomes (Hebbar et al., 2018). We believe that our approach using simulation to promote system-wide evaluation and improvement, rather than individual performance, informs the development of targeted improvement interventions.

In summary, our simulation-based collaborative program demonstrated significant improvement in the CEDs' adherence to PALS SVT guidelines. Our study highlighted the need for alternative venues to improve adherence to PALS guidelines in CEDs beyond recertification classes. This aligns with the AHA Consensus Statement on cardiopulmonary resuscitation quality (Meaney et al., 2013). We postulate that a simulation-based approach will improve CED providers' adherence to PALS guidelines and can expand to other aspects of pediatric care in CEDs.

Limitations

Although this study demonstrated significant improvement in adherence to SVT algorithm, it has several limitations. It included only approximately 10% of the CEDs statewide, which may limit generalizability to other CEDs. Having different groups of participants with more physicians in the follow-up visits is another study limitation, although the improvement that we saw between visits suggests that the education we were hoping to promote extended beyond the baseline simulation teams. We also have not directly measured interrater reliability between the two educators who scored the checklists. All scoring was performed independently by the two educators and then discussed among these educators in real time to resolve any difference in scoring. Although high-fidelity, in situ simulation is designed to be as realistic as possible, inherent errors associated with rare, intermittent technical issues and the inevitable limitations of mannequin use were present. Also, we cannot determine whether team performance in a simulated setting reflects how the team members would perform during real patient scenarios. Yet, there is growing evidence showing that simulation-based mock codes may significantly improve pediatric patient cardiac arrest survival rates, demonstrating a training impact on applied clinical outcomes (Josey et al., 2018).

Conclusions

A collaborative initiative between a pediatric AMC and CEDs using high-fidelity in situ simulation was successful in improving adherence to the PALS SVT algorithm. This model can be adapted to improve CEDs' adherence to other aspects of PALS guidelines in simulated setting and ultimately improved actual pediatric patient outcomes.

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Learning Objectives

Cognitive (Knowledge)Psychomotor (Technical)Behavioral
Recognition of supraventricular tachycardia (SVT) rhythmPerforms vagal maneuver appropriatelyEffective communication among team members including closed loops communication and shared mental model
Recognition of stable versus unstable SVT through vitals and examinationAdministers correct dose of adenosine Administer adenosine using appropriate technique Performs synchronized cardioversion correctlyIdentify need for help/resources utilization

Characteristics of Participating Teams and Hospitals

VariableInitialFollow Up
Team characteristics
  Number of teams3440
  Number of participants173194
  Number of physicians17 (9.8%)28 (14.4%)
  Number of RNs109 (63%)119 (61.3%)
  Number of respiratory therapists16 (9.2%)22 (11.3%)
  Number of others31 (17.9%)25 (12.9%)
  Number of PALS certified120 (69.4%)142 (73.2%)
Site characteristics
  Number of hospitals9
  CED pediatric volumea
    Medium4 (44.4%)
    Medium to high5 (55.6%)
    Presence of inpatient pediatric units7 (77.8%)

Comparison of Adherence to PALS Supraventricular Tachycardia Algorithm Between Baseline and Follow-Up Visits

VariableBaseline, N = 34Follow Up, N = 40p
Checklist itema
  1 Identify/verbalize SVT rhythm29 (85.3%)40 (100%).0173
  2 Identify/verbalize stable versus unstable SVT7 (20.6)23 (57.5%).0019
  3 Perform vagal maneuvers correctly17 (50%)14 (35%).2400
  4 Establish rapid IV/IO access34 (100%)39 (97.5%)1.0000
  5 Administered correct doses of adenosine25 (73.5%)36 (90%).0749
  6 Stopcock/flush technique used20 (58.8%)27 (67.5%).4758
  7 Correct synchronized cardioversion15 (44.1%)29 (74.4%).0158
Median CAS (25th, 75th IQR)57.1 (42.9, 71.4)71.4 (71.4, 85.7).0040

Baseline and Improvement of Supreventrciular Tachycardia Management Based on the Presence of Inpatient Pediatric Units and Community Emergency Department (CED) Pediatric Volume

VariableOverall (N = 9)Inpatient Pediatric UnitsCED Pediatric Volumea


No (n = 2)Yes (n = 7)pMedium (n = 4)Medium-High (n = 5)p
Performance checklist baselineb57.14 (52.38, 66.67)40.48 (28.57, 52.38)61.90 (52.38, 76.19).18064.29 (51.90, 85.71)57.14 (52.38, 61.90).636
Performance checklist improvement from baselineb14.29 (0.95, 20.00)35.12 (23.81, 46.43)9.52 (−4.76, 14.29).09210.48 (−6.67, 21.90)14.29 (9.52, 14.29).905
Authors

Dr. Lutfi is Associate Professor of Clinical Pediatrics and Pediatric Critical Care Service Line Director, Ms. Montgomery is RN, Dr. Berrens is Assistant Professor of Clinical Pediatrics, Dr. Yabrodi is Assistant Professor of Clinical Pediatrics, Dr. Yuknis is Assistant Professor of Clinical Pediatrics, Ms. Kirby is RN, Ms. Pearson is Respiratory Therapist, Dr. Abu-Sultaneh is Associate Professor of Clinical Pediatrics, and Dr. Abulebda is Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Pediatric Critical Care, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana. Dr. Yabrodi is also from the Department of Pediatrics, Division of Pediatric Cardiology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, and Ms. Montgomery, Ms. Kirby, and Ms. Pearson are also from LifeLine Critical Care Transport, Indiana University Health, Indianapolis, Indiana.

This study was supported in part by the Indiana University Health Values Fund for Education (VFE-332-Lufti).

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the members of pediatric critical care division at Riley Hospital for Children at Indiana University Health and Indiana University Health Lifeline for their support and help in this project.

Address correspondence to Riad Lutfi, MD, FAAP, Associate Professor of Clinical Pediatrics and Pediatric Critical Care Service Line Director, Department of Pediatrics, Division of Pediatric Critical Care, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Riley Phase 2 Room 4900, Indianapolis, IN 46202-5225; e-mail: rlutfi@iu.edu.

Received: January 06, 2019
Accepted: April 24, 2019

10.3928/00220124-20190814-06

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