Publications by authors named "Ilana Bank"

21 Publications

  • Page 1 of 1

Decontamination effectiveness and the necessity of innovation in a large-scale disaster simulation.

Am J Disaster Med 2021 Winter;16(1):67-73

Associate Professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Canada.

Background: Chemical, biological, radiologic, nuclear, and explosive (CBRNE) events threaten the health and integrity of human populations across the globe. Effective decontamination is a central component of CBRNE disaster response.

Objective: This paper provides an objective determination of wet decontamination effectiveness through the use of a liquid-based contaminant proxy and describes the mobilization and adaptation of easily available materials for the needs of decontamination in pediatric victims.

Methods: In this in-situ disaster simulation conducted at a pediatric hospital, decontamination effectiveness was determined through a liquid-based contaminant proxy, and standard burn charts to systematically estimate affected total body surface area (TBSA) in 39 adult simulated patients. Two independent raters evaluated TBSA covered by the contaminant before and after decontamination.

Results: On average, simulated patients had 59 percent (95 percent CI [53, 65]) of their TBSA covered by the simulated contaminant prior to decontamination. Following a wet decontamination protocol, the average reduction in TBSA contamination was 81 percent (95 percent CI [74, 88]). There was high inter-rater reliability for TBSA assessment (intraclass correlation coefficient = 0.83, 95 percent CI [0.68, 0.92]. A modified infant bath was tested during the simulated decontamination of infant mannequins and thereafter integrated to the local protocol.

Conclusion: Wet decontamination can remove more than 80 percent of the initial contaminant found on adult simulated patients. The use of a liquid-based visual tool as a contaminant proxy enables the inexpensive evaluation of decontamination performance in a simulated setting. This paper also describes an innovative, low-cost adaptation of a local decontamination protocol to better meet pediatric needs.
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http://dx.doi.org/10.5055/ajdm.2021.0388DOI Listing
May 2021

Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback.

Pediatr Emerg Care 2021 Mar;37(3):133-137

University of Calgary, Calgary, Canada.

Objectives: Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time.

Methods: We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation.

Results: There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05).

Conclusions: There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.
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http://dx.doi.org/10.1097/PEC.0000000000002359DOI Listing
March 2021

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs.

AEM Educ Train 2020 Oct 12;4(4):369-378. Epub 2019 Dec 12.

Yale University School of Medicine New Haven CT.

Objectives: Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs.

Methods: Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items.

Results: A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs.

Conclusions: The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.
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http://dx.doi.org/10.1002/aet2.10412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592831PMC
October 2020

Managing the airway catastrophe: longitudinal simulation-based curriculum to teach airway management.

J Otolaryngol Head Neck Surg 2019 Feb 19;48(1):10. Epub 2019 Feb 19.

Centre for Medical Education, McGill University, Montreal, Canada.

Background: A longitudinal curriculum was developed in conjunction with anesthesiologists, otolaryngologists, emergency physicians and experts in medical simulation and education.

Methods: Residents participated in four different simulation-based training modules using animal models, cadavers, task trainers, and crisis scenarios using high fidelity manikins. Scenarios were based on various clinical settings (i.e. emergency room, operating room) and were followed by video-assisted structured debriefings. Participants completed both a self-assessment questionnaire and an exit survey using five-point Likert scales.

Results: 31 otolaryngology residents participated in the curriculum. Residents reported simulation training significantly improved technical skills such as tracheostomy, cricothyroidotomy and pediatric intubation (p < 0.05 for all). Non-technical skills, including communication, delegation and management were significantly improved on post-test surveys in simulated crisis scenarios (p < 0.05 for all). 90 (28/31) of participants found simulations to be very realistic. Junior residents placed increased value on didactic teaching and procedural skills, while senior residents on crisis scenarios. Survey results indicated that > 90% (28/31) of participants found the modules of the curriculum to be useful and would recommend them to others.

Conclusion: A longitudinal simulation-based medical curriculum can be an effective method to teach airway management and teamwork skills to otolaryngology residents.
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http://dx.doi.org/10.1186/s40463-019-0332-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381681PMC
February 2019

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OTO Open 2018 Apr-Jun;2(2):2473974X18770409. Epub 2018 May 14.

Department of Otolaryngology-Head and Neck Surgery, McGill University, Montréal, Québec, Canada.

Objective: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines.

Methods: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care.

Results: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training.

Discussion: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training.

Implication: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.
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http://dx.doi.org/10.1177/2473974X18770409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239147PMC
May 2018

A call to action: attention to paediatric-specific disaster preparedness.

Arch Dis Child 2019 04 8;104(4):320-321. Epub 2018 Oct 8.

Department of Pediatrics, McGill University, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1136/archdischild-2018-315461DOI Listing
April 2019

Impact of a CPR feedback device on healthcare provider workload during simulated cardiac arrest.

Resuscitation 2018 09 3;130:111-117. Epub 2018 Jul 3.

KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, Canada. Electronic address:

Objective: We aimed to describe the differences in workload between team leaders and CPR providers during a simulated pediatric cardiac arrest, to evaluate the impact of a CPR feedback device on provider workload, and to describe the association between provider workload and the quality of CPR.

Methods: We conducted secondary analysis of data from a randomized trial comparing CPR quality in teams with and without use of a real-time visual CPR feedback device [1]. Healthcare providers (team leaders and CPR providers) completed the NASA Task Load Index survey after participating in a simulated cardiac arrest scenario. The effect of provider roles and real-time feedback on workload were compared with independent t-tests.

Results: Team leaders reported higher levels of mental demand, temporal demand, performance-related workload and frustration, while CPR providers reported comparatively higher physical workload. CPR providers reported significantly higher average workload (control 58.5 vs. feedback 62.3; p = 0.035) with real-time feedback provided compared to the group without feedback. Providers with high workloads (average score >60) had an increased percentage of time with guideline-compliant CPR depth versus those with low workloads (average score <60) (p = 0.034).

Conclusions: Healthcare providers reported high workloads during a simulated pediatric cardiac arrest. Physical and mental workloads differed based on provider role. CPR providers using a CPR feedback device reported increased average workloads. The quality of CPR improved with higher reported physical workloads.
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http://dx.doi.org/10.1016/j.resuscitation.2018.06.035DOI Listing
September 2018

Leadership in crisis situations: merging the interdisciplinary silos.

Leadersh Health Serv (Bradf Engl) 2018 02 24;31(1):110-128. Epub 2017 Nov 24.

Department of Family Medicine, Centre for Medical Education, McGill University , Montreal, Canada.

Purpose Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings Relatively "structured" (predictable) cases were amenable to concrete distributed leadership - the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively "unstructured" (unpredictable) cases required higher-level coordinative leadership - the overall management of the context and allocations of priorities by a designated individual. Originality/value Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.
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http://dx.doi.org/10.1108/LHS-02-2017-0010DOI Listing
February 2018

Invoking the "expectant" triage category: Can we make the paradigm shift?

Am J Disaster Med 2017 ;12(3):167-172

Department of Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University, Montreal, Quebec.

Medical triage is the process of determining the priority of patients' treatments based on the severity of their condition. Triage provides the healthcare provider the ability to identify the most urgent cases first, with the goal of maximizing each individual patient's outcome. When resources are challenged, such as in a disaster, the healthcare provider's goal becomes to maximize overall population survival. In this context, the triage process must identify patients who require resources urgently, as well as those who have the best chance of survival. The revised triage process must include an "expectant management" category, to identify patients for whom further resuscitation is delayed, as they have a poor chance of survival and require significant resources. The paradigm shift that is required in these circumstances can be challenging for pediatric healthcare providers. Many may find themselves unable to change the decision-making process that would favor overall survival and best outcome for the most members of a population, while potentially not addressing the most sick or injured because they have low chances of survival. We hypothesized that participating in a multiprofessional ethics-based educational session regarding making difficult triage decisions may improve participants' perceived ability to use the "expectant" triage category in a disaster setting. Participants took part in an ethics-based educational session and completed a pre- and postsurvey. Results demonstrated a significant change in the participants' self-perceived comfort level using the disaster triage tools and improved their confidence to use the expectant triage category in a disaster setting.
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http://dx.doi.org/10.5055/ajdm.2017.0270DOI Listing
April 2018

The Steinberg Centre for Simulation and Interactive Learning at McGill University.

J Surg Educ 2017 Nov - Dec;74(6):1135-1141. Epub 2017 Jul 5.

Department of Surgery, McGill University, Montreal, Quebec, Canada.

Simulation allows for learner-centered health professions training by providing a safe environment to practice and make mistakes without jeopardizing patient care. It was with this goal in mind that the McGill Medical Simulation Center was officially opened on September 14, 2006, as a partnership between McGill University, the Faculty of Medicine and its affiliated hospitals. Its mandate is to provide state-of-the-art facilities to support simulation-based medical and allied health education initiatives. Since its inception, the center, recently renamed the Steinberg Center for Simulation and Interactive Learning (SCSIL), has undergone a major expansion and logged more than 130,000 learner visits. Educational activities are offered at all levels of medical and allied health care training, and include standardized patient encounters, partial task trainers, multidisciplinary courses, and high-fidelity trainers, among many others. In addition to its educational mandate, the center also supports an active research program, programs to enhance collaboration with disciplines outside of health care to spur innovation, and community outreach initiatives.
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http://dx.doi.org/10.1016/j.jsurg.2017.05.022DOI Listing
August 2018

Errors During Resuscitation: The Impact of Perceived Authority on Delivery of Care.

J Patient Saf 2020 03;16(1):73-78

Section of Critical Care Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.

Objective: The aim of this study was to determine the influence of perceived authority on pediatric resuscitation teams' response to an incorrect order given by a medical superior.

Methods: As part of a larger multicenter prospective interventional study, interprofessional pediatric resuscitation teams (n = 48) participated in a video-recorded simulated resuscitation scenario with an infant in unstable, refractory supraventricular tachycardia. A confederate actor playing a senior physician entered the scenario partway through and ordered the incorrect dose and delivery method of the antiarrhythmic, procainamide. Video recordings were analyzed with a modified Advocacy Inquiry Scale, assessing the teams' ability to challenge the incorrect order, and a novel confederate hierarchical demeanor rating. The association between Advocacy Inquiry score and hierarchical demeanor rating, and whether or not the confederate's incorrect order was followed were determined.

Results: Fifty percent (n = 24) of resuscitation teams followed the confederate's incorrect order. The teams' ability to challenge the incorrect order (P < 0.0001) and confederate hierarchical demeanor rating (P < 0.05) were significantly associated with whether or not the incorrect order was followed. Significant differences between rates of following the incorrect order at different study sites were observed (P < 0.05).

Conclusions: The reluctance of resuscitation teams to appropriately challenge the incorrect order resulted in a high rate of inappropriate medication administration. The rate of teams following the incorrect order was significantly associated with poor challenging of the incorrect order and the hierarchical demeanor of the perceived authority figure. Institution-based factors may impact this rate of incorrect medication administration.
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http://dx.doi.org/10.1097/PTS.0000000000000359DOI Listing
March 2020

Error Detection-Based Model to Assess Educational Outcomes in Crisis Resource Management Training: A Pilot Study.

Otolaryngol Head Neck Surg 2017 06 25;156(6):1080-1083. Epub 2017 Apr 25.

1 Department of Otolaryngology-Head and Neck Surgery, McGill University, Montréal, Canada.

Otolaryngology-head and neck surgery (OTL-HNS) residents face a variety of difficult, high-stress situations, which may occur early in their training. Since these events occur infrequently, simulation-based learning has become an important part of residents' training and is already well established in fields such as anesthesia and emergency medicine. In the domain of OTL-HNS, it is gradually gaining in popularity. Crisis Resource Management (CRM), a program adapted from the aviation industry, aims to improve outcomes of crisis situations by attempting to mitigate human errors. Some examples of CRM principles include cultivating situational awareness; promoting proper use of available resources; and improving rapid decision making, particularly in high-acuity, low-frequency clinical situations. Our pilot project sought to integrate CRM principles into an airway simulation course for OTL-HNS residents, but most important, it evaluated whether learning objectives were met, through use of a novel error identification model.
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http://dx.doi.org/10.1177/0194599817697946DOI Listing
June 2017

An Approach to Confederate Training Within the Context of Simulation-Based Research.

Simul Healthc 2016 Oct;11(5):357-362

From the Pediatrics and Medical Education (M.D.A.), Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Hasbro Children's Hospital (F.O.), Alpert Medical School of Brown University, Providence, RI; The Children's Hospital of Philadelphia (V.M.N.), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; KidSIM-ASPIRE Simulation Research Program (J.D.), Alberta Children's Hospital University of Calgary; Montreal Children's Hospital (R.G., I.B.), McGill University, Montreal, QC, Canada; Baystate Children's Hospital (K.M.), Springfield, MA; Yale-New Haven Health (S.S), New Haven, CT; and KidSIM-ASPIRE Simulation Research Program (V.J.G., A.C.), Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute University of Calgary, Calgary, AB, Canada.

Statement: Simulation-based education often relies on confederates, who provide information or perform clinical tasks during simulation scenarios, to play roles. Although there is experience with confederates in their more routine performance within educational programs, there is little literature on the training of confederates in the context of simulation-based research. The CPR CARES multicenter research study design included 2 confederate roles, in which confederates' behavior was tightly scripted to avoid confounding primary outcome measures. In this report, we describe our training process, our method of adherence assessment, and suggest next steps regarding confederate training scholarship.
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http://dx.doi.org/10.1097/SIH.0000000000000172DOI Listing
October 2016

Are Pediatric Emergency Physicians More Knowledgeable and Confident to Respond to a Pediatric Disaster after an Experiential Learning Experience?

Prehosp Disaster Med 2016 Oct 11;31(5):551-6. Epub 2016 Aug 11.

Division of Pediatric Emergency Medicine,Montreal Children's Hospital,McGill University,Montreal,Quebec,Canada.

Objectives: Pediatric hospital disaster responders must be well-trained and prepared to manage children in a mass-casualty incident. Simulations of various types have been the traditional way of testing hospital disaster plans and training hospital staff in skills that are used in rare circumstances. The objective of this longitudinal, survey-based, observational study was to assess the effect of disaster response and management-based experiential learning on the knowledge and confidence of advanced learners.

Methods: A simulation-based workshop was created for practicing Pediatric Emergency Medicine (PEM) physicians, senior PEM physicians, and critical care and pediatric surgery residents to learn how to manage a disaster response. Given that this particular group of learners had never been exposed to such a disaster simulation, its educational value was assessed with the goal of improving the quality of the hospital pediatric medical response to a disaster by increasing the responders' knowledge and confidence. Objective and subjective measures were analyzed using both a retrospective, pre-post survey, as well as case-based evaluation grids.

Results: The simulation workshop improved the learners' perceived ability to manage patients in a disaster context and identified strengths and areas needing improvement for patient care within the disaster context.

Conclusion: Advanced learners exposed to an experiential learning activity believed that it improved their ability to manage patients in a disaster situation and felt that it was valuable to their learning. Their confidence was preserved six months later. Bank I , Khalil E . Are pediatric emergency physicians more knowledgeable and confident to respond to a pediatric disaster after an experiential learning experience? Prehosp Disaster Med. 2016;31(5):551-556.
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http://dx.doi.org/10.1017/S1049023X16000704DOI Listing
October 2016

Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions.

Resuscitation 2015 Dec 28;97:13-9. Epub 2015 Sep 28.

The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA. Electronic address:

Aim: The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest.

Methods: We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate.

Results: We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001).

Conclusion: The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.
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http://dx.doi.org/10.1016/j.resuscitation.2015.08.024DOI Listing
December 2015

Determining content for a simulation-based curriculum in pediatric emergency medicine: results from a national Delphi process.

CJEM 2015 Nov 20;17(6):662-9. Epub 2015 May 20.

†McGill Centre for Medical Education,McGill University,Montreal,QC.

Objectives: By the end of residency training, pediatric emergency medicine (PEM) residents are expected to have developed the confidence and abilities required to manage acutely ill children. Acquisition of competence requires exposure and/or supplemental formal education for critical and noncritical medical clinical presentations. Simulation can provide experiential learning and can improve trainees' knowledge, skills, and attitudes. The primary objective of this project was to identify the content for a simulation-based national curriculum for PEM training.

Methods: We recruited participants for the Delphi study by contacting current PEM program directors and immediate past program directors as well as simulation experts at all of the Canadian PEM fellowship sites. We determined the appropriate core content for the Delphi study by combining the PEM core content requirements of the Royal College of Physicians and Surgeons of Canada (RCPSC) and the American Board of Pediatrics (ABP). Using the Delphi method, we achieved consensus amongst the national group of PEM and simulation experts. The participants completed a three-round Delphi (using a four-point Likert scale).

Results: Response rates for the Delphi were 85% for the first round and 77% for second and third rounds. From the initial 224 topics, 53 were eliminated (scored <2). Eighty-five topics scored between 2 and 3, and 87 scored between 3 and 4. The 48 topics, which were scored between 3.5 and 4.0, were labeled as "key curriculum topics."

Conclusion: We have iteratively identified a consensus for the content of a national simulation-based curriculum.
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http://dx.doi.org/10.1017/cem.2015.11DOI Listing
November 2015

Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial.

JAMA Pediatr 2015 Feb;169(2):137-44

Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines.

Objective: To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA.

Design, Setting, And Participants: Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams).

Interventions: Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA.

Main Outcomes And Measures: The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA.

Results: The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation.

Conclusions And Relevance: The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes.

Trial Registration: clinicaltrials.gov Identifier: NCT02075450.
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http://dx.doi.org/10.1001/jamapediatrics.2014.2616DOI Listing
February 2015

Pediatric resuscitation training-instruction all at once or spaced over time?

Resuscitation 2015 Mar 13;88:6-11. Epub 2014 Dec 13.

McGill Centre for Medical Education, Montreal, QC, Canada; Department of Pediatrics, McGill University, Montreal, QC, Canada; Pediatric Emergency Medicine, Montreal Children's Hospital-McGill University Health Center, Montreal, QC, Canada; Arnold and Blema Steinberg Centre for Medical Simulation, Montreal, QC, Canada; Centre for Medical Education, McGill University, Canada; Royal College of Physicians and Surgeons of Canada, Canada.

Aim: Healthcare providers demonstrate limited retention of knowledge and skills in the months following completion of a resuscitation course. Resuscitation courses are typically taught in a massed format (over 1-2 days) however studies in education psychology have suggested that spacing training may result in improved learning and retention. Our study explored the impact of spaced instruction compared to traditional massed instruction on learner knowledge and pediatric resuscitation skills.

Methods: Medical students completed a pediatric resuscitation course in either a spaced or massed format. Four weeks following course completion students completed a knowledge exam and blinded observers used expert-developed checklists to assess student performance of three skills (bag-valve mask ventilation (BVMV), intra-osseous insertion (IOI) and chest compressions (CC)).

Results: Forty-five out of 48 students completed the study protocol. Students in both groups had similar scores on the knowledge exam spaced: (37.8±6.1) vs. massed (34.3±7.6)(p<0.09) and overall global rating scale scores for IOI, BVMV and CC; however students in the spaced group also performed critical procedural elements more frequently than those in the massed training group

Conclusion: Learner knowledge and performance of procedural skills in pediatric resuscitation taught in a spaced format is at least as good as learning in a massed format. Procedures learned in a spaced format may result in better retention of skills when compared to massed training.
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http://dx.doi.org/10.1016/j.resuscitation.2014.12.003DOI Listing
March 2015

Accuracy of ultrasonography for determining successful realignment of pediatric forearm fractures.

Ann Emerg Med 2015 Mar 16;65(3):260-5. Epub 2014 Oct 16.

Clinical Research Centre, Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada.

Study Objective: The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures. The secondary objective is to determine the rate of agreement of ultrasonography and fluoroscopy in real-time by the treating physician.

Methods: A cross-sectional study was conducted in children younger than 18 years and presenting to an academic emergency department with forearm fractures requiring realignment of a single bone. Physicians performed closed reductions with ultrasonographic assessment of realignment until the best possible reduction was achieved. Fluoroscopy was then immediately performed and images were saved. A positive test result was defined as an inadequately reduced fracture on fluoroscopy by a blinded pediatric orthopedic surgeon (reference standard) and on ultrasonography (index test) and fluoroscopy in real-time by the treating physician.

Results: One hundred patients were enrolled (median age 12.1 years; 74% male patients); the radius was involved in 98%, with 27% involving the growth plate. The sensitivity, specificity, positive predictive value, and negative predictive value were 50% (95% confidence interval [CI] 15.4% to 84.6%), 89.1% (95% CI 82.8% to 95.5%), 28.6% (95% CI 4.9% to 52.2%), and 95.3% (95% CI 90.9% to 99.8%), respectively. The treating physicians' agreement rate of the real-time images was 98%.

Conclusion: Point-of-care ultrasonography can help emergency physicians determine when pediatric forearm fractures have been adequately realigned, but inadequate reductions should be confirmed by other imaging modalities.
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http://dx.doi.org/10.1016/j.annemergmed.2014.08.043DOI Listing
March 2015

Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.

Pediatr Emerg Care 2014 Dec;30(12):879-83

From the *Division of Pediatric Emergency Medicine, †Arnold and Blema Steinberg Medical Simulation Center, ‡Center for Medical Education, §Division of General Internal Medicine, and ∥Department of Pediatrics, McGill University, Montreal, Quebec, Canada.

Objectives: Improved pediatric crisis resource management (CRM) training is needed in emergency medicine residencies because of the variable nature of exposure to critically ill pediatric patients during training. We created a short, needs-based pediatric CRM simulation workshop with postactivity follow-up to determine retention of CRM knowledge. Our aims were to provide a realistic learning experience for residents and to help the learners recognize common errors in teamwork and improve their perceived abilities to manage ill pediatric patients.

Methods: Residents participated in a 4-hour objectives-based workshop derived from a formal needs assessment. To quantify their subjective abilities to manage pediatric cases, the residents completed a postworkshop survey (with a retrospective precomponent to assess perceived change). Ability to identify CRM errors was determined via a written assessment of scripted errors in a prerecorded video observed before and 1 month after completion of the workshop.

Results: Fifteen of the 16 eligible emergency medicine residents (postgraduate year 1-5) attended the workshop and completed the surveys. There were significant differences in 15 of 16 retrospective pre to post survey items using the Wilcoxon rank sum test for non-parametric data. These included ability to be an effective team leader in general (P < 0.008), delegating tasks appropriately (P < 0.009), and ability to ensure closed-loop communication (P < 0.008). There was a significant improvement in identification of CRM errors through the use of the video assessment from 3 of the 12 CRM errors to 7 of the 12 CRM errors (P < 0.006).

Conclusions: The pediatric CRM simulation-based workshop improved the residents' self-perceptions of their pediatric CRM abilities and improved their performance on a video assessment task.
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http://dx.doi.org/10.1097/PEC.0000000000000302DOI Listing
December 2014

Sudden cardiac death in association with the ketogenic diet.

Pediatr Neurol 2008 Dec;39(6):429-31

Department of Pediatrics, Montreal Children's Hospital and the McGill University Health Centre, Montreal, Quebec, Canada.

The ketogenic diet is a high-fat, low-carbohydrate, adequate-protein diet that is used to decrease the frequency of seizures in patients who have refractory epilepsy. Despite its positive effects in some patients, there are potential adverse effects. Two complications related to the ketogenic diet are selenium deficiency, which has been associated with impaired myocardial function, and QT prolongation as documented on electrocardiography. Reported here are two cases of death in a child on the ketogenic diet for seizure control. In case 1, the child who died of complications related to torsade de pointes, with documented QT prolongation; post mortem examination revealed selenium-deficiency cardiomyopathy. In case 2, a child experienced QT prolongation while on the ketogenic diet and later died suddenly at home. Both children exhibited selenium deficiency. These two cases suggest that patients on the ketogenic diet require monitoring of the QT interval by electrocardiography, myocardial function by echocardiography, and selenium levels before and during the ketogenic diet.
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http://dx.doi.org/10.1016/j.pediatrneurol.2008.08.013DOI Listing
December 2008