Abstract
Background: Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals. Methods: Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues. Results: Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues. Conclusions: This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.
| Original language | English (US) |
|---|---|
| Article number | e10558 |
| Journal | AEM Education and Training |
| Volume | 5 |
| Issue number | 3 |
| DOIs | |
| State | Published - Jul 2021 |
ASJC Scopus subject areas
- Emergency
- Education
- Emergency Medicine
Access to Document
Other files and links
Fingerprint
Dive into the research topics of 'The Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals'. Together they form a unique fingerprint.Cite this
- APA
- Standard
- Harvard
- Vancouver
- Author
- BIBTEX
- RIS
In: AEM Education and Training, Vol. 5, No. 3, e10558, 07.2021.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - The Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals
AU - Auerbach, Marc
AU - Patterson, Mary
AU - Mills, William A.
AU - Katznelson, Jessica
N1 - Funding Information: Grant support was provided from NIH AHRQ R18‐1R18HS024220‐01A, Improving Rural Pediatric Emergency Care Through Tele‐Simulation to Johns Hopkins, University of North Carolina, and Yale University to conduct research conceived and written (MA, MP, WM, JK). Funding Information: All CAHs in North Carolina that had not previously participated in a pediatric simulation study and that did not conduct simulation sessions for their ED providers were eligible to participate. We worked with the State Office of Rural Health to determine eligibility, and the chief operating officer at each of the eligible hospitals was approached to request participation. Fifteen of the 20 CAHs in North Carolina met eligibility criteria. Three hospitals with diverse geography in the state and connections with distinct hospital systems were recruited to participate. All three were similar in size and in the number of pediatric patients seen annually in their ED. (Table 1). The participating hospitals did not have their own institutional review board (IRB) and the IRB at Johns Hopkins was utilized as the IRB of record with the written consent of each institution (Johns Hopkins School of Medicine IRB No. O0103156). Written informed consent was waived. The study was funded by the Agency for Healthcare Research and Quality NIH-AHRQ R18-1R18HS024220-01A. [Corrections added on 8 May 2021, after first online publication: Funding has been changed to “NIH-AHRQ R18-1R18HS024220-01A” in this section.]. Each participating ED nurse manager served as a local on-site project champion and acted as the in-person liaison for the facilitators located off site. Prior to the first simulation, pilot testing of technology and equipment was conducted via in-person site visits by an investigator (WM) traveling to each participating ED and working with the remote facilitator (MA) and the local information technology team to test the Internet connectivity to support the telecommunications platform. Next this pilot visit involved training the ED nurse manager on the set up of the simulator and equipment to support the session. Finally, the remote facilitator joined via a video-conferencing platform to test running a scenario. The pilot sessions involved iterative adaptation of technology until sessions could be run smoothly at each site with the development of plans for redundancy (e.g., use of iPad in addition to laptop and an external speaker to augment sound). The audiovisual feed for each session utilized Zoom (San Jose, CA) teleconferencing platform with a backup redundancy plan to use Apple Facetime (Cupertino, CA) should the bandwidth be insufficient. A facilitator (MA) joined from New Haven, CT, and was responsible for running the software and facilitating in the role of the parent. A second facilitator (JK) joined from Baltimore, MD, to collect data on checklists and augment the debriefings. The facilitators alternated serving in the role of the lead and codebriefer for each session. All debriefings used the established PEARLS framework31 to guide a facilitated discussion. Debriefings involved five phases: setting the scene, reactions, description, analysis, and application/summary. An Apple iPad mounted to an IV pole was used to provide a face-to-face video connection via Zoom between the facilitators and the local participants. This enabled the facilitators to see the room and view and hear the participants during the simulation sessions (Figure 1A). The iPad and Zoom platform also allowed the facilitator to act in the role of parent during the scenarios and enabled the facilitators and participants to interact face to face for the debriefing (Figure 1B). An external speaker was used in addition to the iPad to amplify the audio volume from the facilitators. The Zoom platform allowed for recording of the audio and visual feeds as well as the monitor output. The off-site facilitators were provided access to the local laptop via TeamViewer remote desktop tool (Göppingen, Germany). Through that laptop, the remote facilitators used Laerdal’s LLEAP (Stavinger, Norway) software platform to run preprogrammed case scenarios that resulted in changes in vital signs and physiology over time and in response to interventions. The Laerdal SimJunior (Stavinger, Norway) simulator was used for all sessions to represent an approximately 6-year-old child. A tablet connected to the laptop served as a monitor displaying the patient’s vital signs and labs/imaging. The remote facilitators are board certified in PEM and have more than 10 years of experience in PEM, simulation, and debriefing. A screen shot of the facilitators’ laptop is provided in Figure 2. A single simulator was loaned to the study team by the manufacturer (Laerdal), who agreed in writing to not review any of the data or results prior to publication and to have no input into where or how the data were presented or published. The mannequin was delivered via Federal Express to the hospital the day prior to each simulation session and returned immediately following the sessions. The functionality of this simulator allows for heart sounds, breath sounds, pulses, chest rise with breathing, anatomically correct airway for procedures including intubation, ECG outputs, IV/IO access, and shaking for seizure activity. The iPads were purchased through the study grant and the laptops were repurposed from other projects. On the day of each session, the onsite champion coordinated unpacking and setting up the simulator and ensured that the monitor, medications, and associated equipment were available in the ED resuscitation room. Expired medications or labeled vials of saline were used so that no actual medications had to be wasted. Prior to the participants arrival, the remote facilitators and champion worked together to confirm the simulator, the telecommunications platform, and the monitor software all functioned properly. Each session began with a standardized orientation to introduce the project, describe the format for the session (15-minute simulation and 30-minute debrief), communicate the rules and expectations, introduce the remote facilitators, and orient participants to the functionality of the simulators. This discussion included demonstrating how to place the simulator on a monitor and how to administer medications and fluids. Laboratory data and imaging results were provided on request during the scenarios. Contextually rich, standardized, case scenarios were chosen to represent a broad spectrum of pediatric ED cases with an emphasis on those that may be high risk in settings that see few children. The study team had previously created and conducted over 20 different pediatric ED-focused simulation case scenarios designed for use in community-based general ED settings, including CAHs. Cases for this study were drawn and adapted from this list of simulations. In addition to existing epidemiologic data and prior needs assessments, feedback was gathered from CAH ED providers who had participated in prior simulation studies and used to guide the case selection by the study lead investigators. All scenarios involved seriously ill or injured pediatric patients, with a focus on pediatric-specific problems and presentations or instances where the pediatric treatment may diverge from the standard adult care (see Table 2 for list of scenarios). *All cases were conducted using a 5-year-old-sized mannequin Eight cases were conducted over a 12-month period in the same order at each site. Simulation days at each of the EDs were run sequentially over 3 days of the same week each month. Each case was run twice per site, back to back—once each for the day and night shift. Teams were not notified prior to their shift that the simulation session would be occurring. After the first team completed the scenario, the champion and remote facilitators reset the room/equipment. A set of guidelines was agreed upon to iterate when patient care necessitated delaying or cancelling the simulation. Each team included nurses, physicians, respiratory therapists, and nursing assistants. Team size was based on the local staffing models. Students and trainees, if present in the department, were allowed to observe but not participate in the scenarios. All sessions were video recorded for later review by the study team. Simulation success/failure was collected by the principal investigators for each session with success involving completion of the simulation with or without technical issues and failure requiring cancellation due to technical or nontechnical issues. All participants completed a brief, anonymous, paper survey assessing their feedback on the scenario immediately following the debriefing and prior to leaving the simulation room. The survey asked about their role on the medical team followed by six questions regarding team performance and six questions regarding the use of simulation as a teaching modality. All questions were answered on a 5-point Likert scale from “strongly disagree” through “strongly agree.” Staff were offered the opportunity at the end of the survey to free text any comments they had (see Data Supplement S1 [available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10558/full] for full survey). Surveys were collected by the nurse manager prior to staff leaving the simulation room and were forwarded to the primary investigator (JK) for entry into a REDCap database. Data were collected on the number of simulation events conducted and the number of cancellations. Additional data were collected on technical or logistic issues encountered during the simulation. Survey data were analyzed using Microsoft Excel using descriptive statistics. Publisher Copyright: © 2020 by the Society for Academic Emergency Medicine
PY - 2021/7
Y1 - 2021/7
N2 - Background: Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals. Methods: Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues. Results: Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues. Conclusions: This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.
AB - Background: Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals. Methods: Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues. Results: Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues. Conclusions: This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.
UR - http://www.scopus.com/inward/record.url?scp=85100022089&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85100022089&partnerID=8YFLogxK
U2 - 10.1002/aet2.10558
DO - 10.1002/aet2.10558
M3 - Article
C2 - 34124506
AN - SCOPUS:85100022089
SN - 2472-5390
VL - 5
JO - AEM Education and Training
JF - AEM Education and Training
IS - 3
M1 - e10558
ER -