Simulation and educationPediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training☆
Introduction
Over 5800 children will have an in-hospital cardiac arrest (IHCA) in the United States each year.1 An exciting trend reveals survival to discharge from pediatric IHCA improving from 14.3% in 2000 to 43.9% in 2009, however, the majority of children will still not survive.2 Deviance from American Heart Association (AHA) resuscitation guidelines is associated with decreased likelihood of survival from IHCA.3, 4 AHA recommends pulseless individuals receive chest compressions immediately, defibrillation within 2 min of a shockable rhythm and no pauses in chest compressions >10 s.5, 6
In an initial “pre-intervention” study of simulated cardiopulmonary arrests (sCPAs), only 1/3 of pediatric residents started compressions within 1 min from onset of pulseless ventricular tachycardia (PVT), and less than half defibrillated within 2 min. There was no difference between first-year and third-year residents, suggesting Basic Life Support (BLS), Pediatric Advanced Life Support (PALS) and residency were not preparing them to manage IHCAs.7 At our institution, we have now augmented BLS and PALS courses with curricula focused on acquisition of procedural and teamwork skills. As described below, this novel competency-based curriculum style is referred to as “Rapid Cycle Deliberate Practice” (RCDP).
The first principle of RCDP is to maximize the time learners spend in deliberate practice. We give them multiple opportunities to “do it right”, applying the concepts of overlearning and automatization, creating muscle memory for the “right way”.8, 9, 10 The second is for faculty to efficiently provide specific evidence-based or expert-derived solutions for common problems seen during IHCAs. This is more efficient than encouraging residents to explore new solutions. The third principle is to explicitly foster “psychological safety” so learners embrace our direct feedback without becoming defensive.11, 12 We create an environment where residents understand our goal is coaching them akin to world-class athletes, with high standards and even higher stakes, i.e. saving lives. They transition from being nervous about making mistakes to being enthusiastic about the opportunity for dedicated coaching and practice time. We rapidly cycle between deliberate practice and directed feedback until skill mastery is achieved, thus the rationale for referencing K. Anders Ericsson's work on deliberate practice as the inspiration for the term “Rapid Cycle Deliberate Practice”.13
The objective of this study was to measure if implementation of an intervention, i.e. RCDP curriculum, was associated with: (1) improved performance on key resuscitation quality markers when compared to a baseline cohort from our initial pre-intervention study and (2) a measurable improvement between first and third-year pediatric residents.7
Section snippets
Pre-intervention baseline resuscitation curriculum
The pre-intervention resuscitation curriculum consisted of BLS during intern orientation, PALS at the beginning of second year, monthly in situ mock-codes on the wards described previously and sporadic mock codes on other rotations.14 Greater detail regarding the pre-intervention cohort baseline characteristics was reported previously.7, 14, 15
Intervention
The post-intervention resuscitation training was identical to pre-intervention except: (1) PALS was moved from beginning of second-year to the end of
Baseline characteristics
Seventy pediatric residents participated in the pre-intervention period and fifty-one in the post-intervention period. Baseline characteristics are stratified by cohort and reported in Table 1. Resuscitation training was similar between the two cohorts except fewer of the post-intervention cohort had training in advanced cardiopulmonary life support and more had exposure to simulators during medical school. As expected, more post-intervention than pre-intervention residents had taken PALS since
Discussion
We present the results of a prospective pre-post interventional study of pediatric resident performance during simulated sCPAs. Our analysis revealed an association between the RCDP-FFM curriculum and marked improvement in quality measures of BLS and defibrillation. This manuscript introduces an innovative teaching style we call “Rapid Cycle Deliberate Practice”, which enables rapid attainment of competence in resuscitation performance skills.
Conclusion
This study revealed the RCDP-FFM curriculum was associated with improved performance by pediatric residents during sCPAs in nearly all measures of resuscitation. Future investigation is needed to see if RCDP-FFM is effective when implemented at other institutions and with other topic areas. Additionally, research is needed to determine if the benefits observed in simulation associated with our intervention translate to clinical practice, thus reducing error, improving performance, and
Contributor's statement
All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
Funding source
The Pearl Stetler Foundation and the NIH Loan Repayment Program supported Dr. Elizabeth Hunt's contributions.
Dr. Hunt was funded by a Pearl Stetler Grant for Women Researchers and received NIH loan repayment in relation to the content of this manuscript. Dr Hunt also received grant funding for work unrelated to this project from the Laerdal Foundation for Acute Medicine, the Arthur Vining-Davis Foundation, the Hartwell Foundation and the American Heart Association. Mr Duval-Arnould is funded by
Conflict of interest statement
The authors have no conflict of interest to report.
Acknowledgements
We would like to thank the Johns Hopkins pediatric residents and chief residents for their dedication to learning how to resuscitate critically ill children. We would like to thank Walter Eppich, MD, MEd for his unique insights into the Rapid Cycle Deliberate Practice Curriculum. Finally, we would like to acknowledge K. Anders Ericsson, PhD for his body of work describing the contribution of Deliberate Practice in attaining expertise, on which our work is based.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.02.025.