PEDIATRICS Vol. 117 No. 3 March 2006, pp. 641-648 (doi:10.1542/peds.2004-2702)
Simulation of Pediatric Trauma Stabilization in 35 North Carolina Emergency Departments: Identification of Targets for Performance Improvement
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
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ABSTRACT |
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 TOP ABSTRACT ObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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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
TRAUMA IS THEleading cause of death in children.1 In the 1970s, an effective effort was made to improve emergency services, and data collected in the 1980s showed that where systems of trauma care had been developed, deaths from accidental injuries had significantly decreased in adults. Unfortunately, deaths from accidental injuries had not decreased in children.2,3
In 1984, the federal government established the Emergency Medical Services for Children Program to ensure that the unique needs of children are met within the emergency medical services system, originally designed for adults. One of the first steps was to develop protocols and training programs for the resuscitation of children. This engendered the pediatric advanced life support (PALS) and advanced pediatric life support courses developed in the late 1980s.
Another early step was to recognize that although the development of regional trauma systems is very important for the care of children, of the "30 million children seen in the emergency departments (EDs) each year, 81% are seen in smaller community hospital EDs."4–7 The American Academy of Pediatrics stated that "community hospitals must have the equipment and skilled personnel necessary to recognize, stabilize and support the timely transport of pediatric patients to a prearranged definitive care resource."8 Multiple organizations have demonstrated their support of this view.8–12
Simulation has been used successfully as both a method to assess clinical skills and to enhance teaching of adult trauma management.13–15 This study uses simulation to evaluate the performance of ED health care teams during the management of traumatically injured children.
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Objective |
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TOPABSTRACTObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The objective of this study was to perform a prospective observational study of a random sampling of North Carolina EDs by using simulated pediatric trauma resuscitations, commonly called "mock codes," to (1) characterize the quality of resuscitation efforts and (2) identify problem areas as targets for educational interventions.
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METHODS |
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TOPABSTRACTObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Sample Selection
We obtained a list of all hospitals in North Carolina that have EDs. Thirty-five hospitals and 5 alternates were chosen randomly from the list. Study personnel contacted each hospital and asked for their agreement to participate in the study. If the hospital representative did not agree to participate, the study personnel contacted the hospital listed next as an alternate. The number 35 served as a convenience sample for this study and represented more than one third of the EDs in North Carolina.
Simulated Pediatric Trauma Stabilizations: Mock Codes
Study personnel contacted an administrator from each hospital to arrange a visit that would be a "surprise" to nurses and physicians in their EDs. Study personnel arrived unannounced to the ED triage area with a child-sized mannequin. The same prescripted vignette was used for every mock code. To standardize the mock codes at each study ED, the script included information on the initial presentation of the patient, the planned clinical progression, and vital signs.
The initial clinical vignette communicated to the triage nurse was that of a 3-year-old child brought in by his mother. The nurse was told that the child had fallen off a tall slide, did not move for a while, and had been very sleepy since the fall. He was described as lying quietly in his mother's arms and breathing spontaneously, with dried blood on his face. The triage nurse was instructed to proceed as though this were a true emergency. He/she would eventually decide to move the mannequin to a trauma bay in the ED. Study personnel provided information from a script as the physicians, nurses, and other team members assessed and "treated" the mannequin.
Evaluation
We designed a tool with which to score each mock code. The tool was adapted from one developed by a multidisciplinary expert panel at the North Carolina Office of Emergency Medical Services. It was used originally in rating medical providers during a judged simulation exercise and was modified to include ED procedures. The tool was based on resuscitation courses that are considered the standard of care for the treatment of critically ill children and trauma patients: (1) the American Heart Association PALS; (2) the American College of Surgeon's advanced trauma life support (ATLS); and (3) the Emergency Nurses Association trauma nurse core course (TNCC).16–18 The tool was divided into 3 sections: (1) primary survey; (2) secondary survey; and (3) procedures.
Each of the 44 items comprising the tool represented a specific stabilization task. The stabilization tasks were initially assigned a possible point value ranging from 1 to 5, weighted by importance of the task. Subsequently, we converted the numerical scores assigned for each task to a dichotomous score to facilitate ease of use of the tool, that is, "meets expectations" or "needs improvement" (eg, on tasks originally assigned a 5-point value, a score of 4 or 5 was converted to "meets expectations," and 1, 2, or 3 was considered "needs improvement"). Whereas each resuscitation task was assigned a score, we did not assign an overall qualitative score for each mock code (ie, pass/fail), because this study was designed to elucidate current performance and identify targets for future educational interventions.
One to 2 study personnel simultaneously and independently used the tool to score performance of the team on the mock code in real time. The script and assessment tool are presented in a modified format in Tables 1–4.
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Data Analysis
The proportion of EDs that needs improvement for each stabilization task was calculated to identify targets for future educational interventions. Each of the EDs was given a total overall score by calculating the percentage of the 44 stabilization tasks in which they need improvement. We specifically compared EDs that achieved the highest scores (ie, "highest 20%") versus EDs with the lowest scores, (ie, "lowest 23%"). The EDs with the seventh- and eighth-lowest scores had the same score; therefore, we used the lowest 23% rather than 20%. Explorations were made to identify stabilization tasks in which the performance on that particular task by an ED was associated with overall performance. No attempt was made to analyze the correlation between patient volumes or trauma level with performance, because reporting of these data would have resulted in "identification" of performance by specific centers because of the small number of trauma centers. Categorical data were compared through use of Fisher's exact test, because there was always a cell with an expected value of <5. A 2-sided P value of
.05 was considered statistically significant. Interrater reliability was assessed by performing a weighted 
-statistic function. |
RESULTS |
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TOPABSTRACTObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Baseline Characteristics
Of the first 36 EDs contacted, 35 agreed to participate and were enrolled in the study after receiving assurance that all of the data would be collected in a deidentified manner. The sites included predominantly community hospitals (30 of 35), but there were also 5 trauma centers (5 of 35), including level I, II, and III facilities. The annual ED patient volumes for the participating hospitals ranged from 5228 to 107499 visits per year, with a median of 30918. None of the hospitals in the study had a separate pediatric ED, but 1 hospital had a separate area designated for children.
Interrater Reliability
All 35 of the mock codes were evaluated by either 1 or 2 study personnel (K.S.F. and S.M.H.). Of the 35 mock codes, 18 (51%) were simultaneously and independently observed and scored by both reviewers. The weighted value was 0.77 (95% confidence interval: 0.74–0.79), which is generally interpreted as excellent interrater reliability.
Analysis by Stabilization Task
The performance of EDs varied dramatically on the various stabilization tasks. The results are summarized in Tables 1–4 as the percentage of EDs that need improvement in each stabilization task. Some tasks were performed as expected by most and were in need of improvement in only a few EDs (eg, initial assessment of vital signs: 4 of 35 [11%]), whereas other tasks showed scores that indicated need for improvement by most EDs (eg, warming measures: 34 of 35 [97%]).
Stabilization Tasks Most Frequently Performed Well ("As Expected")
Of the 44 stabilization tasks, 7 (16%) were performed as expected by 
28 (80%) of 35 centers (Tables 1–4). The tasks that were most likely to be performed as expected in increasing order of frequency included (1) taking the patient from triage to the resuscitation room immediately (28 of 35 [80%]), (2) calling appropriate team members for assistance (28 of 35 [80%]), (3) making initial immediate assessment of airway and breathing (28 of 35 [80%]), (4) initiating bag-mask ventilation when the patient desaturated and became hypopneic after seizing (29 of 35 [83%]), (5) ordering appropriate trauma radiographs (30 of 35 [86%]), (6) ordering head computed tomography (CT) (30 of 35 [86%]), and (7) making the initial assessment of vital signs (31 of 35 [89%]).
Stabilization Tasks Most Frequently in Need of Improvement
As shown in Tables 1–4, 80% of the 35 EDs scored as "needs improvement" in 11 of the 44 stabilization tasks (25%) included in the simulated exercise. These problem categories, in increasing order of frequency, included (1) assessment and stabilization of the cervical spine (28 of 35 [80%]), (2) assessment of the pelvis (28 of 35 [80%]), (3) offering support to the parent (28 of 35 [80%]), (4) using suction for the airway (30 of 35 [86%]), (5) correctly ordering intravenous fluid boluses (31 of 35 [89%]), (6) assessing injury to the shoulders (33 of 35 [94%]), (7) assessing injury to the upper extremities (33 of 35 [94%]), (8) performing rectal examination (33 of 35 [94%]), (9) removing clothing (34 of 35 [97%]), (10) applying warming measures (34 of 35 [97%]), and (11) correctly ordering dextrose for hypoglycemia (34 of 35 [97%]).
Analysis by ED
Analysis was also performed by looking at the specific EDs as the units of analysis. No ED performed as expected on every stabilization task. Every ED scored "in need of improvement" on 8 (18%) of the 44 tasks, and some needed improvement in as many as 32 (73%) of 44 stabilization tasks. The median number of stabilization tasks that needed improvement was 25 (57%) of 44.
Comparison of EDs With Scores in Highest 20% Versus Lowest 23%
Table 5 summarizes the stabilization tasks that were significantly more likely to be performed as expected in EDs for which the total mock-code score was in the highest 20% versus those in the lowest 23%. All of the EDs in the top 20% adequately prepared the patient to be transported for CT, whereas none of the lowest 20% EDs did so (P = .007). Of the 7 EDs, 6 (86%) in the top 20% performed as expected in (1) administration of oxygen, (2) assessment of circulation, and (3) preparation for intraosseous placement, whereas only 1 (13%) of 8 of the lowest 23% of EDs performed as expected on those tasks (P = .01). There was also a significant difference in the proportion of highest- versus lowest-performing EDs that successfully (1) estimated the patient's weight (highest 20%, 5 of 7 [71%], versus lowest 23%, 1 of 8 [13%]; P = .04) and (2) assessed and stabilized the cervical spine (highest 20%, 4 of 7 [57%], versus lowest 23%, 0 of 8 [0%]; P = .03).
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DISCUSSION |
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TOPABSTRACTObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In this study, we visited one third of all EDs in North Carolina to examine the quality of stabilization efforts delivered to critically injured children. We used simulated pediatric trauma stabilization, that is, mock codes, to examine the types of mistakes made to most effectively target future educational interventions. Through simulation, a standardized scenario can be presented to multiple health care teams, thus providing the opportunity to compare trauma stabilization efforts across institutions.
This study was unique in that we were able to observe 35 health care teams in action in their own environment. Despite the surprise nature of the mock codes, without exception, the nurses, physicians, and other health care personnel were immediately willing to suspend disbelief and participate in the exercise. They were eager to receive feedback and frequently asked if the study team would return for future mock codes.
Targets for Future Interventions
Primary Survey
The mock codes revealed patterns that are important to delineate. Arguably, the initial steps of resuscitation are the most important to master; they are often referred to as the "primary survey." EDs of which the overall performance was in the highest 20% were very likely to perform the steps prioritized by the PALS, ATLS, and TNCC courses, including assessment of the airway, breathing, and circulation; assessment of neurologic status; and stabilization of the cervical spine.16–18 Unfortunately, a review of all 35 EDs showed that performance of these important initial stabilization tasks was often inadequate; 20–80% of the EDs needed improvement in at least 1 of these important components of the primary survey (Table 1). In addition, during debriefing, we discovered that, whereas every ED had a plan to stabilize the spine of the traumatically injured child (eg, towel roll), not all of the EDs (including the trauma centers) had adequately sized cervical collars for the smallest children.
Time-Dependent Therapy
In the field of medicine, the likelihood of successful treatment is time-dependent in several clinical entities. Septic shock is an example of such a clinical entity. Han et al19 demonstrated that when community physicians followed the American College of Critical Care Medicine PALS guidelines for treatment of septic shock by initiating the appropriate therapy early, the absolute risk reduction of mortality was 30% compared with when the guidelines were not followed (ie, 8% vs 38%). For traumatic injuries, the term "the golden hour" exemplifies this concept. Vernon et al20 performed a case-control study that compared the outcomes of critically injured children at a level I pediatric trauma center before and after they reorganized existing resources to improve trauma-team response. Their study demonstrated a significant decrease in time to CT scan, time to the operating room, and improved survival compared with the reference population. Although our study did not consistently measure and document the time elapsed to perform the components of the primary survey, the mock codes suggested that an intervention that increases the number of EDs that always follow appropriate order and time frames within standard algorithms might also improve clinical outcomes.
Stabilization Tasks Unique to Pediatrics
Additional analysis of the mock codes revealed problems with stabilization tasks that are uniquely important and/or complicated in pediatric resuscitations. For example, 17 (49%) of 35 EDs failed to correctly estimate the child's weight. One method that theoretically simplifies the cognitive load associated with varying weights of children is the use of a resuscitation aid, such as the Broselow-Luten (color-coded) tape.21 Although all of the EDs (35 of 35) had a Broselow tape, less than half (15 of 35 [43%]) used it correctly. Rapid estimation of the weight of a child is essential to choosing appropriate equipment sizes and doses of medications, fluids, and defibrillation. Of 7 of the highest 20% of EDs, 5 (71%) successfully estimated the child's weight, whereas only 1 (13%) of 8 EDs in the lowest 23% did so (P = .04). Improving the manner in which EDs rapidly estimate weight and choose weight-based therapy may be a high-yield target for educational interventions. We have reported previously our observations regarding use of the Broselow-Luten tape, educational modules created to improve the use of the tape, and competency checklists to assess its use.22–25 It is imperative that the pediatric community continue to investigate resuscitation aides that may achieve these essential improvements.
Rapid Vascular Access
Vascular access is another clinical task that is often managed differently in pediatric versus adult trauma resuscitations. Gaining peripheral or central venous access in a volume-depleted or cold child can be quite difficult; thus, PALS calls for prompt consideration of intraosseous access as a noncollapsible venous structure.16 Physicians and nurses who are less experienced with children may delay attempts to obtain intraosseous access because of a lack of experience or lack of appreciation of its value. Despite the fact that the "child" in our simulated scenario was described as having a heart rate of 160 and extremities that were cool to the touch, 24 (69%) of the 35 EDs failed to successfully prepare for intraosseous needle placement when told that they had failed 3 peripheral venous access attempts. It is of interest that 6 (86%) of 7 of the highest-scoring 20% EDs successfully prepared for intraosseous placement, whereas only 1 (13%) of 8 of the lowest 23% EDs did so (P = .01). We should note that during the debriefing period, the study team confirmed that intraosseous needles were available at all 35 of the EDs. However, not all of the teams recognized what the needle was or how it was to be used; for example, some were marked "bone marrow aspiration needle." This is a clear target for future educational interventions.
Preparation for Safe Intrahospital Transport
Our mock codes also revealed an interesting pattern regarding the use of CT scans in trauma management. Of the 35 EDs, 30 (86%) successfully recognized that a child who experiences loss of consciousness at the scene after head injury with subsequent seizures requires a head CT. Only 21 (60%) of the 35 EDs considered whether additional personnel, such as a physician or respiratory therapist, should accompany the nurse during transport to the CT scanner to ensure the child's safety. Even fewer EDs, 12 (34%) of 35, adequately geared up for safe transport in terms of preparation of appropriate medications, monitoring, and personnel. All of the highest 20% of EDs (7) adequately prepared the child for transport to CT, whereas 0 of 8 of the lowest 23% of EDs did so (P = .007). A review of the literature reveals multiple studies that suggested that a particularly high-risk time for patients is during intrahospital transport, including 1 that demonstrated a decrease in adverse events during transports after the introduction of specialized monitoring and transport equipment.26–29 Our study revealed that hospitals should consider analyzing their policies to ensure safe intrahospital transport as a promising target for improving the outcomes of critically injured children in the hospital setting.
Limitations
Our study has several limitations. We measured performance of the mock codes with a tool that has not been validated. However, the tool was patterned after PALS, ATLS, and TNCC algorithms and was reviewed by an expert group of emergency care practitioners who agreed that the tool tested important elements of resuscitation. The 2 independent observers demonstrated excellent interrater reliability. Quan et al30 demonstrated the reliability of resuscitation-skill checklists and their ability to detect improvement after PALS training. They also pointed out that a particularly useful aspect of the checklist is that it reported "failed" (ie, needs improvement) items, which provided immediate targets for feedback. We also found this to be the case. Tables 1–4 present the resuscitation tasks and associated script of the tool; thus, the user may determine which aspects of the tool that they find useful or problematic.
It is difficult to ensure that mock codes were adequate surrogates for reality, and we cannot confirm that performance on a simulated exercise reflects how one would perform in a real resuscitation. A growing body of evidence suggests that performance in a simulated setting can be used as a powerful skills-assessment tool and as an educational intervention tool, but this remains a valid question.13–15,31,32 Regardless, in this study, simulation provided us with unique opportunities. The use of prescripted vignettes allowed us to standardize the scenario presented to each ED. Simulation also allowed us to observe pediatric trauma stabilization at each ED in a timely manner. In addition, the mock codes were performed in the actual clinical work area of each facility using their own equipment and resources. This contributed to our ability to infer how the teams would perform in real pediatric trauma resuscitations and offered us an opportunity to identify the source of failure on stabilization tasks, that is, organization of equipment, communication, availability of resuscitation aides, and so forth.
Finally, we would like to have analyzed whether EDs designated as trauma centers had higher mock-code scores. Unfortunately, the small proportion of trauma centers in our sample did not allow us to perform such analysis. In addition, to obtain consent to perform the mock codes at these hospitals, we agreed to maintain confidentiality about the performance of each center and not to report any information in a manner that could be used to identify any center's performance, including patient volume. There has been much debate about whether the existence of designated pediatric trauma centers positively impacts the outcomes of injured children and whether centers with a higher volume of patients are able to deliver higher quality of care.33–36 As stated in the introduction, however, 81% of children in the United States present to community hospitals for emergent care; thus, it is essential that all EDs be capable of successfully managing the initial aspects of care for critically ill or injured children.
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CONCLUSIONS |
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TOPABSTRACTObjectiveMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study used simulation to identify deficiencies in the resuscitation of children in EDs in North Carolina. Our mock codes revealed that mistakes were ubiquitous and demonstrated the need for additional training. It is important to note that our ongoing studies suggest that these findings are not unique to North Carolina. Simulations in other states have identified similar problems. These results identify targets for future interventions, including education to improve the proportions of EDs that successfully (1) assess, reassess, and manage airway, breathing, circulation, and initial neurologic status, (2) estimate the pediatric patient's weight, (3) rapidly place intraosseous needles, (4) prepare to safely transport the child, (5) apply warming measures, (6) order intravenous fluid boluses, and (7) order the appropriate dose and concentration of dextrose for hypoglycemia. ED personnel were universally receptive to directed feedback and indicated willingness to collaborate in educational initiatives to improve trauma stabilization performance. Future research should investigate whether educational interventions that focused on the identified deficiencies can improve the performance of EDs and, ultimately, the outcomes of the children who present to them.
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ACKNOWLEDGMENTS |
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This work was supported by Maternal and Child Health Bureau grant 5H33 MC00101-03.
We acknowledge Peter J. Pronovost, MD, PhD, and Anne Marie Guerguerian, MD, for insightful comments during the article preparation. In addition, we thank Tzipora Sofare, MA, for excellent editorial assistance in preparing this article. Finally, we thank the health care providers from the 35 North Carolina EDs who so graciously and enthusiastically participated in the mock codes.
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FOOTNOTES |
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Accepted May 5, 2005.
Address correspondence to Elizabeth A. Hunt, MD, MPH, 600 N Wolfe St, Blalock 904, Baltimore, MD 21287. E-mail: ehunt{at}jhmi.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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