Previous generations of health care providers have learned acute care medicine based on the “see one, do one, teach one” mantra, while the current generation of trainees have the opportunity to practice to perfection in simulation, grounded in the principles of improving patient safety and outcomes (22
). Our curriculum safely increased resident exposure to critically ill children in a realistic, yet controlled, environment, while concurrently addressing RCPSC and ACGME learning objectives required for certification of training. Furthermore, an emerging body of evidence suggests that the greatest benefit of simulation may reside in its ability to train multidisciplinary teams, help identify human errors, and modify team behaviour leading to a reduction in medical errors (23
). In one study, Hunt et al (26
) examined 34 unannounced, hospital-based paediatric mock codes and found that 100% had communication errors and represented an important opportunity to improve real patient outcomes. We addressed this need throughout our curriculum by using multidisciplinary teams whenever possible, discussing communication and teamwork issues during all debriefing sessions, and focusing our final modular course on CRM skills. Our survey data reflect this potential benefit with the strongest scores occurring in the areas of communication and teamwork.
The evidence also suggests that teaching resuscitation through Paediatric Advanced Life Support courses and didactic lectures lead to significant decay in knowledge and skills (8
). Without the reinforcement of regular hands-on practice, subsequent resuscitations on real patients are likely to be suboptimal. A recent review of existing best practices for resuscitation education coincidently included reducing course duration and instead distributing practice sessions over time (27
). It also suggested maximizing the time spent in deliberate practice on manikins, constructing scenarios that match the learners’ usual clinical practice, and integrating simulation into resuscitation curricula. In addition, a recent study has shown that as few as two ‘rolling refreshers’ per month in the critical care setting using just-in-time CPR training can improve performance in subsequent real resuscitations (28
). In designing our own curriculum and considering the evidence, the concept of just-in-time mock codes was incorporated to address multiple learning needs simultaneously. First, they were distributed at monthly intervals to allow regular hands-on practice and help prevent knowledge and skill decay. Second, they were multidisciplinary and involved the actual paediatric code team to help identify and reduce team-work and communication errors. Third and most importantly, just-in-time mock codes were as realistic as possible and meant to be predictive of patient deterioration. By using real patient information and documents in combination with a portable paediatric simulator, we were able to recruit the actual bedside nurse and have the responsible CTU residents as first responders. This not only enhanced the situational and emotional realism, but often identified issues with actual equipment, access to resources, and other obstacles to a timely response that are otherwise difficult to recognize. In essence, just-in-time mock codes trained the human element and primed the surrounding crisis support systems to have the greatest potential for improving our sick children’s care.
Our curriculum was by no means a static proposition but an evolving educational process. In comparison to the simulation-based curriculum for paediatric emergency fellows at our centre (18
), our residency trainees’ learning objectives varied widely. From the first-year resident with minimal clinical experience to the fourth year resident who will soon graduate to assume responsibilities as a community paediatrician, we approximated the steep learning curve with our integrated curriculum framework while allowing for flexibility in the longitudinal growth of any given cohort as they pass through the curriculum. In accordance, we noted an evolution in perceived value of various teaching methods at different stages of training. First-year resident survey scores and feedback suggested greater relative benefit from lectures and may reflect increased knowledge gaps. In comparison, second-year residents appreciated the hands-on procedural skills and complex medical simulation scenarios, while senior resident feedback emphasized the benefit of focused teaching on communication and leadership skills. Each year-specific course built upon the foundation from the previous, every just-in-time mock code reinforced the knowledge and skills that could have potentially been lost, and annual needs assessments ensured that the curriculum continued to adapt. While many paediatric centres have used simulation in some capacity, our experience suggests that an understanding of your centre’s unique resources and opportunities, an evolving assessment of your trainees’ needs, combined with a commitment to an integrated and longitudinal approach for teaching resuscitation through simulation, may have the most lasting impact on future generations of trainees and their patients.
Our study’s primary limitation was that we were not able to evaluate resident performance because the study design did not include a pre- and postintervention comparison or control group. However, studies have shown positive correlations between resident self-assessment surveys and performance in resuscitation team leadership skills and critical resuscitation procedures (29
). The overall curriculum surveys may have been susceptible to recall bias because they were performed at least six months after the trainees’ modular course, but this increased the likelihood of both participating in just-in-time mock codes and having the opportunity to apply their learning in real situations. Future research is needed to determine the impact of educational interventions such as ours on resuscitation performance and patient outcomes.