Pediatric Sim Training Delivers Results
For a family taking home an infant with a tracheostomy and ventilator, the reality of all that could go wrong can be “horrifying,” says Amanda Spears, mom to fifteen-month-old Christian Zachary Spears, a patient of Texas Children’s Hospital. But on the day when a complication with his tracheostomy tube caused her young son to stop breathing, Amanda knew exactly how to provide life-saving care—using a device known as an Ambu bag to provide manual breaths for respiratory support—while waiting for paramedics to arrive.
“We immediately started chest compressions,” Amanda Spears recalled. “Around the third cycle of us doing chest compressions and bagging him, he started breathing again. We bagged him until the paramedics showed up. They were just amazed with how well we handled the situation. Of course, emotions were high. But we were able to keep cool because we had actually been in this situation—not in real life, but in training. We had practice and preparation for that moment.”
While all parents of infants on a ventilator with a tracheostomy go through standard training before the infant is released from the hospital, Amanda took part in a pilot program offered through the Texas Children’s Hospital Simulation Center. She trained for four different airway emergencies using a high-fidelity mannequin fitted with a tracheostomy tube.
“The high fidelity, or high tech mannequins that we use in simulations are very realistic. They do many things a real baby would do, providing an opportunity for traditionally health care providers, and now laypersons to practice management of life threatening situations. Our babies turn blue—signaling oxygen deficiency—breathe, cry, and have pulses,” explained Jennifer Arnold, M.D., neonatologist at Texas Children’s Hospital and medical director of the Texas Children’s Simulation Center. “We always say that the technology is great, and that’s what usually gets people excited about simulation, but it’s not about the technology. These high tech mannequins are just a tool to allow a learner to really practice what they would do in a real situation and get immediate feedback from the ‘patient.’ It’s really about the learning experience.”
Texas Children’s releases as many as fifty patients a year on ventilators, and hospital educators hope that hands-on training for various airway emergencies could help decrease mortality and readmission rates. Nationally, tracheostomy-related airway emergencies after discharge from the hospital account for three percent of deaths in this patient population.
In this simulation training program, trainees are given a series of tracheostomy-related airway scenarios—including a tracheostomy tube obstruction or a power failure—and are tasked with addressing the simulated emergencies with the skills they were taught in the classroom. As the trainees work through a scenario, simulation center educators are watching from a separate room, and video recording the exercise to refer back later during a one-on-one debriefing.
“The immersion aspect of simulation is just so powerful. You may forget what you heard in lecture, but you will never forget the mistake you made during a mock code,” said Martin Lorin, M.D., professor of pediatrics at Baylor College of Medicine and senior teaching faculty member with Texas Children’s Simulation Center. “As we say, a mistake made in simulation is a mistake that will not be made in real-life.
The family training pilot program, which ended in July and is currently becoming a part of the discharge education process for these patients and their families, is just one of the programs offered to deliver more personalized, hands-on training for families, physicians, and local first responders. The goal is to improve communication and provide a safe, controlled environment in which teams and individuals can prepare to handle high-risk medical situations.
In addition to the neonatal and pediatric mannequins, the simulation center also trains with a birthing simulator. They practice performing a complicated delivery, stabilizing mom and baby, and then transferring the baby to the team in the neonatal intensive care unit. It’s an opportunity to bring together all of the different individuals and teams that may play a role in the care of a single patient.
“I think what really makes our program unique is the emphasis on patient safety,” said Arnold. “Our priority is to improve medical errors, because we know that in our health care systems about 60 to 70 percent of medical errors are due to deficiencies in communication and teamwork. We really try to embed those crisis resource management skills into all of our simulations.
“For example, maybe the team leader calls for a dose of epinephrine and they don’t say it specifically to one person. So two people are drawing up doses of epinephrine and two doses are given, or no one draws it up because it was a request in the air and everyone else thinks someone else is doing it and it doesn’t happen,” she added. “So the human factor has a play in medical errors. It’s not because people aren’t well trained or well intended. It’s just we don’t often get to practice as a team. Simulation provides an opportunity in real time to practice how we work together in a crisis.”
Even for personnel familiar with routine training and real-world medical emergencies, the chance to review decisions and outcomes in a controlled setting can be invaluable.
“Experience alone does not teach us everything we need to know about how to manage critical events and avoid errors,” said Kelly Wallin, assistant director of Texas Children’s Simulation Center. “By examining what happened—or did not happen—afterward with each team member in the room, we discover important information that would otherwise have been missed. And when it comes to talking about mistakes, we can create an environment where it is safe for people to talk about and learn from their mistakes.”
The team tries to run trainees through the most realistic scenarios possible, in hopes of preparing them to calmly and confidently care for a patient in a situation they might one day actually encounter. One of their training scenarios actually played out in a real-life scenario earlier this year when a baby was delivered in the parking lane outside of Texas Children’s. Lobby staff and medical personnel responded quickly to care for mom and baby.
“We practiced that scenario,” said Wallin. “We had done that in simulation before. I had to believe that lobby staff was so confident in their ability because we ran them through that scenario so many times.”