Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training

Abstract

Introduction

Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing.

Participants

Pediatric residents from an academic medical center.

Methods

Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation.

Results

Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p < 0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p = 0.01], and pre-shock pause: [pre: 84 s (26–162) vs. post: 8 s (4–18); p < 0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5–5.1)].

Conclusions

Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

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