Learner Development Through Simulation in Pediatric Cardiac Critical Care

Pediatric cardiac critical care has become increasingly complex, requiring highly trained, multi-disciplinary teams to provide comprehensive care for children with heart disease. Providers such as physicians, nurses, and advanced practice providers may come from various training backgrounds.¹ A vital component of ensuring the quality of care we provide is recognizing the need for competency and performance-based metrics (such as entrustable professional activities (EPAs), defined as observable activities that measure the learner’s ability to perform the task independently). Learners can then be assessed for each task based on specific learning objectives, and with the provision of effective feedback, build graduated responsibility and competency in specific domains. Efforts have already been made to standardize learning objectives for pediatric critical care training programs and to develop EPAs specific to pediatric cardiac intensivists.^2,3

Simulation-based training is a frequently used educational modality for trainees and staff at all levels to enhance competency in knowledge and skills in a low-stakes environment. Simulation-based mastery learning (SBML) is a competency-based educational intervention where the participants’ skills are measured against a rigorous, standardized achievement benchmark called the minimum passing standard.⁴ In a paper by Barsuk et. al, a SBML program for thoracentesis skills for internal medicine trainees improved rates of clinically meaningful complications compared to trainees without the SBML intervention.⁵ SBML has also been shown to improve retention of skills, including self-care skills for adult patients with a ventricular assist device (VAD).^6,7

Temporary pacemakers are crucial to perioperative cardiac ICU patient management. However, temporary pacemaker management is not always straightforward to teach since temporary leads are prone to poor electrical characteristics and fracture. Additionally, inappropriate management can cause significant hemodynamic compromise which complicates safe bedside teaching. Given these issues, simulation-based medical education is perfectly suited to acquiring the skills to manage temporary pacemakers safely and reliably. Dr. Ahmad Sami Chaouki, MD, PhD, a pediatric electrophysiologist at Ann & Robert H. Lurie Children’s Hospital, is in the process of building an SBML curriculum for cardiac ICU providers at all levels using a novel temporary pacemaker simulator. His team has collaborated with our institution’s department of biomedical engineering to construct the Automated Rhythm Management Simulator, capable of generating any imaginable rhythm. It can then transmit human-like signals to real pacemakers allowing for management with the actual equipment in use in the unit. The pacemakers can be programmed by the learner, and the device will respond to the pacemaker’s outputs in a realistic manner. Dr. Chaouki’s team has already built a functional prototype, which has been met with enthusiasm by our learners who find it a reliable representation of real-life scenarios. As the device becomes more integrated into an SBML curriculum and more devices are built, we look forward to expanding to other institutions.

Healthcare professionals should be lifelong learners.⁸ After knowledge and skills are gained in pediatric cardiac critical care, regardless of training background, simulation-based continuing education and professional development initiatives can help with retention. In the spirit of this, please join us at the PCICS pre-conference bedside nursing, advanced practice provider and fellow/junior faculty bootcamp session on Thursday, December 15^th. Topics include airway specific management in congenital heart disease and cardiopulmonary interactions. We will also have multi-disciplinary simulation sessions on communication strategies, pediatric VAD management, single ventricle physiology, hands-on practice with a temporary pacemaker simulator, and more. We hope to see you there.

1. McBride ME, Beke DM, Fortenberry JD, et al. Education and Training in Pediatric Cardiac Critical Care. World J Pediatr Congenit Heart Surg. Nov 2017;8(6):707-714. doi:10.1177/2150135117727258
2. Tabbutt S, Krawczeski C, McBride M, et al. Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care. Pediatr Crit Care Med. Sep 22 2021;doi:10.1097/pcc.0000000000002815
3. Werho DK, DeWitt AG, Owens ST, McBride ME, van Schaik S, Roth SJ. Establishing Entrustable Professional Activities in Pediatric Cardiac Critical Care. Pediatr Crit Care Med. Sep 22 2021;doi:10.1097/pcc.0000000000002833
4. McGaghie W. Mastery Learning: Origins, Features, and Evidence from the Health Professions. In: McGaghie W, Barsuk J, Wayne D, eds. Comprehensive Healthcare Simulation: Mastery Learning in Health Professions Education. Springer; 2020:27-46:chap Chapter 2.
5. Barsuk JH, Cohen ER, Williams MV, et al. Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. Acad Med. May 2018;93(5):729-735. doi:10.1097/acm.0000000000001965
6. Barsuk JH, Wilcox JE, Cohen ER, et al. Simulation-Based Mastery Learning Improves Patient and Caregiver Ventricular Assist Device Self-Care Skills: A Randomized Pilot Trial. Circ Cardiovasc Qual Outcomes. Oct 2019;12(10):e005794. doi:10.1161/circoutcomes.119.005794
7. Barsuk JH, Cohen ER, Cameron KA, et al. Short-term Retention of Patient and Caregiver Ventricular Assist Device Self-care Skills after Simulation-based Mastery Learning. Clin Simul Nurs. Apr 2021;53:1-9. doi:10.1016/j.ecns.2021.01.004
8. Institute of Medicine (US) Committee on Planning a Continuing Health Professional Education Institute. Redesigning Continuing Education in the Health Professions. Washington (DC): National Academies Press (US); 2010. 1, Continuing Professional Development: Building and Sustaining a Quality Workforce.Available from: https://www.ncbi.nlm.nih.gov/books/NBK219809/