Editorial
“Changing the focus” for simulation-based education assessment… not simply “changing the view” with videolaryngoscopy
a University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Philadelphia, United States
b University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, Department of Pediatrics, Philadelphia, United States
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"apellidos" => "Nadkarni" "email" => array:1 [ 0 => "Nadkarni@email.chop.edu" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rodrigo J." "apellidos" => "Daly Guris" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Ellen S." "apellidos" => "Deutsch" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Philadelphia, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, Department of Pediatrics, Philadelphia, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tracheal intubation is a critical life-saving procedure performed by pediatric healthcare providers to support critically ill and injured children. These children often have challenging airway anatomy, low oxygen reserve, and unstable hemodynamics with high risk for severe desaturation and other adverse tracheal intubation-associated events.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These short-term adverse outcomes during tracheal intubation are associated with worse long-term outcomes: longer duration of mechanical ventilation and ICU stay, and higher mortality.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pediatric tracheal intubation in the emergency department is a low-volume and high-risk procedure, especially when performed by pediatric residents.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The age-old training adage of “see one, do one, teach one” on real patients during pediatric residency training is slowly being replaced by the emergence, dissemination, and labor intensive but effective implementation of simulation-based education.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> In this issue of <span class="elsevierStyleItalic">Jornal de Pediatria</span>, Couto et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> describe how they are “changing the view” in airway management education. They describe the impact of simulation-based mastery learning with directed practice to teach residents how to transition from using their usual direct view of the larynx with a standard laryngoscope, to a new technology-augmented view through videolaryngoscopy. Using a checklist based upon “work as imagined,” Couto et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> implemented a simulation-based educational intervention to teach videolaryngoscopy, trained until learners achieved “mastery level” performance on manikins to assess “work as simulated,” and then assessed the impact of simulation-based educational interventions on real patient intubation process of care and outcomes in the emergency department (“work as done”).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> In fact, they have gone far beyond “changing the view.” They have completely changed the “lens” and shifted the “focus” from measuring theoretical improvements in processes of care and outcomes on manikins to actual processes of care and outcomes for real patients!</p><p id="par0010" class="elsevierStylePara elsevierViewall">The two-year, single-center, retrospective cohort study by Couto et al. included 59 pediatric physician trainees who voluntarily completed a simulation-based mastery learning intervention early in their second year of residency, prior to rotation in their hospital emergency department. The tracheal intubation skills evaluation checklist completed by trained observers included measurable cognitive, behavioral, and technical metrics, with appropriate attention to validation for reliability and inter-rater consistency. Within 30 min to two hours of training, 100% of trainees were successfully trained to achieve prospectively designated mastery-level performance on manikins. This general approach, of deliberate practice and mastery learning, has previously been reported as effective for procedural skill training.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> What is particularly impressive in Couto et al.’s study<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> is the attention to five important components which support successful implementation of new technology or processes of care into the clinical environment: 1) proactive training on new techniques with the sharp-end providers who will actually be deploying them, 2) “bundling” the introduction of the new technology with specific training on that technology, 3) mastery-level instead of minimal competence training goals, 4) measuring and documenting the acquisition of the skill (uptake) in a simulated realistic environment after training has been completed, and 5) assessing transfer of the procedural skill acquired during simulation to safe and effective performance on real patients in real care environments. Indeed, this study reports an impressive improvement from a previously published historical first-attempt tracheal intubation success rate of 39%,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> to a much improved 78% success rate. The associated 26% adverse tracheal intubation outcome (severe desaturation and/or other adverse event during intubation) rate is now comparable to the 24–31% rate reported from the NEAR4KIDS international registry for critically ill children across multiple centers.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors do acknowledge several important limitations of this study. As a single-center study, the training and approach was contextualized to the learners, facilitators, and environment of this particular hospital and training program. It is difficult to know if this is generalizable to other settings. In addition, the pre-intervention clinical data was historical and general, and demonstrated a very low baseline performance of residents (39% historical success rate). Whether the time, effort, and commitment of faculty and trainees would provide effective return on investment if the baseline performance started at a more typical (higher) level cannot be determined without a concurrent and contemporary control group. Finally, the size and type of videolaryngoscopy equipment available at the time of the study was limited to sizes only appropriate for children over the age of 1 year, thus intubation attempts on infants under the age of 1 year could not be included. Of note, these younger infants often have challenging airways and little respiratory reserve, making them prone to desaturation and other adverse events during tracheal intubation.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite these acknowledged limitations, this study should be heralded as a landmark in the evolution from traditional “see one, do one, teach one” apprenticeship paradigms of medical education to a more contemporary simulation-enhanced healthcare system with embedded learning.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> The report by Couto et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> illuminates the opportunity to integrate simulation and validated summative assessments to more profoundly inform learner achievements of procedural milestones, teamwork, crew resource management, and clinical competence while acknowledging consistent barriers to dissemination and implementation of simulation-based education. These barriers include time constraints of faculty, trainees, and simulation support staff combined with omnipresent funding challenges for both simulation and residency training programs.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,18–20</span></a> This landmark study not only literally “changes the view” for the specific procedure of tracheal intubation with videolaryngoscopy, but “changes the lens and the focus” through which we should judge future educational intervention studies. With thought, diligence, and perseverance there is now evidence that transformative educational interventions can permeate to enrich our trainee clinician performance and – most importantly – to benefit our patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">Unrelated to content: Dr. Nadkarni receives unrestricted research grants to his institution (University of Pennsylvania) from the National Institutes of Health, Agency for Healthcare Research and Quality, American Heart Association, Zoll Medical Corporation, and Nihon-Kohden Incorporated. He is an uncompensated volunteer on the Executive Committees for the Society of Critical Care Medicine, the Citizen CPR Foundation, and the International Liaison Committee on Resuscitation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Unrelated to content: Dr. Deutsch receives an unrestricted research grant to her institution from the National Institutes of Health. She is an uncompensated volunteer on the Executive Committee for the International Pediatric Simulation Society.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nadkarni VM, Daly Guris RJ, Deutsch ES. Changing the focus” for simulation-based education assessment… not simply “changing the view” with videolaryngoscopy. J Pediatr (Rio J). 2021;97:4–6.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Couto et al. in pages 30–36.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Nishisaki" 1 => "D.A. Turner" 2 => "C.A. Brown" 3 => "R.M. Walls" 4 => "V.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 4 | 11 |
| 2024 October | 35 | 18 | 53 |
| 2024 September | 60 | 30 | 90 |
| 2024 August | 35 | 25 | 60 |
| 2024 July | 37 | 48 | 85 |
| 2024 June | 17 | 36 | 53 |
| 2024 May | 39 | 11 | 50 |
| 2024 April | 50 | 23 | 73 |
| 2024 March | 19 | 19 | 38 |
| 2024 February | 20 | 33 | 53 |
| 2024 January | 18 | 31 | 49 |
| 2023 December | 31 | 23 | 54 |
| 2023 November | 50 | 35 | 85 |
| 2023 October | 29 | 30 | 59 |
| 2023 September | 23 | 41 | 64 |
| 2023 August | 19 | 18 | 37 |
| 2023 July | 42 | 13 | 55 |
| 2023 June | 41 | 18 | 59 |
| 2023 May | 18 | 16 | 34 |
| 2023 April | 20 | 15 | 35 |
| 2023 March | 36 | 16 | 52 |
| 2023 February | 17 | 17 | 34 |
| 2023 January | 23 | 28 | 51 |
| 2022 December | 36 | 27 | 63 |
| 2022 November | 35 | 20 | 55 |
| 2022 October | 39 | 45 | 84 |
| 2022 September | 25 | 39 | 64 |
| 2022 August | 34 | 35 | 69 |
| 2022 July | 28 | 32 | 60 |
| 2022 June | 28 | 31 | 59 |
| 2022 May | 20 | 39 | 59 |
| 2022 April | 63 | 25 | 88 |
| 2022 March | 35 | 38 | 73 |
| 2022 February | 15 | 25 | 40 |
| 2022 January | 15 | 21 | 36 |
| 2021 December | 22 | 17 | 39 |
| 2021 November | 19 | 16 | 35 |
| 2021 October | 16 | 17 | 33 |
| 2021 September | 21 | 14 | 35 |
| 2021 August | 14 | 9 | 23 |
| 2021 July | 14 | 12 | 26 |
| 2021 June | 11 | 9 | 20 |
| 2021 May | 19 | 8 | 27 |
| 2021 April | 28 | 44 | 72 |
| 2021 March | 36 | 13 | 49 |
| 2021 February | 48 | 16 | 64 |
| 2021 January | 68 | 19 | 87 |
| 2020 December | 6 | 5 | 11 |
| 2020 November | 16 | 15 | 31 |
| 2020 October | 11 | 11 | 22 |
| 2020 September | 14 | 9 | 23 |
| 2020 August | 20 | 12 | 32 |
| 2020 July | 6 | 6 | 12 |
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