Published online March 1, 2006
PEDIATRICS Vol. 117 No. 3 March 2006, pp. 641-648 (doi:10.1542/peds.2004-2702)
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Simulation of Pediatric Trauma Stabilization in 35 North Carolina Emergency Departments: Identification of Targets for Performance Improvement

Elizabeth A. Hunt, MD, MPHa,b,c, Susan M. Hohenhaus, MA, RN, FAENd,e, Xuemei Luo, PhDe,f,g and Karen S. Frush, MDd,e,g

a Department of Anesthesiology and Critical Care Medicine
b Simulation Center
c Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
d Department of Pediatrics
f Center for Clinical Effectiveness
g Department of Surgery
e Duke University Medical Center, Duke University, Durham, North Carolina

OBJECTIVE. Trauma is the leading cause of death in children. Most children present to community hospital emergency departments (EDs) for initial stabilization. Thus, all EDs must be prepared to care for injured children. The objectives of this study were to (1) characterize the quality of trauma stabilization efforts in EDs and (2) identify targets for educational interventions.

METHODS. This was a prospective observational study of simulated trauma stabilizations, that is, "mock codes," at 35 North Carolina EDs. An evaluation tool was created to score each mock code on 44 stabilization tasks. Primary outcomes were (1) interrater reliability of tool, (2) overall performance by each ED, and (3) performance per stabilization task.

RESULTS. Evaluation-tool interrater reliability was excellent. The median number of stabilization tasks that needed improvement by the EDs was 25 (57%) of 44 tasks. Although problems were numerous and varied, many EDs need improvement in tasks uniquely important and/or complicated in pediatric resuscitations, including (1) estimating a child's weight (17 of 35 EDs [49%]), (2) preparing for intraosseous needle placement (24 of 35 [69%]), (3) ordering intravenous fluid boluses (31 of 35 [89%]), (4) applying warming measures (34 of 35 [97%]), and (5) ordering dextrose for hypoglycemia (34 of 35 [97%]).

CONCLUSIONS. This study used simulation to identify deficiencies in stabilization of children presenting to EDs, revealing that mistakes are ubiquitous. ED personnel were universally receptive to feedback. Future research should investigate whether interventions aimed at improving identified deficiencies can improve trauma stabilization performance and, ultimately, the outcomes of children who present to EDs.

Key Words: patient simulation • mock code • emergency preparedness • medical education • pediatric emergency

Abbreviations: PALS—pediatric advanced life support • ED—emergency department • ATLS—advanced trauma life support • TNCC—trauma nurse core course • CT—computed tomography

Accepted May 5, 2005.




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