Auswirkung fallbasierter Simulationstrainings auf das Atemwegsmanagement bei simulierten pädiatrischen Reanimationen an hessischen Kinderkliniken

In this study, we evaluated the effect of simulation-based training on airway management during simulated pediatric resuscitations. For the study, the author performed a blinded and retrospective analysis of 113 videos of simulated pediatric resuscitations. The videos were recorded before and after (Pretest and Posttest) a structured PALS Training in 12 pediatric hospitals in Hesse, Germany. All the participating teams completed the same pre- and posttest scenario to facilitate a comparison. The scenarios were scripted and followed a set routine. The pre- and posttest scenario differed only in the patient’s history, the vital signs were exactly the same. In both cases, the simulated patient was a toddler. When presented to the team, the child was critically ill, but still in compensated shock, which inevitably deteriorated to cardiac arrest during the course of the scenario. The airway management of the teams was evaluated using a performance evaluation checklist (PEC) and then checked regarding adherence to current ERC pediatric resuscitation guidelines. The key points, where we hypothesized, that improvement could become evident, were the evaluation of the airway of a critically ill child, early recognition and therapy of apnea, airway management during resuscitation and the successful implementation of other life-support measures, like chest compression, defibrillation, and the application of drugs. Furthermore, we tried to evaluate if the existence of a PICU in a hospital affects airway management during a simulated resuscitation. The data we obtained from our analysis showed, that, initially, almost all the teams used bag mask ventilation. A significant improvement was seen in the choice of the equipment used. While in the pretest more than half of the teams used inadequately sized equipment, it was only a third in the posttest. We documented an intubation rate of 55% in the pretest, which sank to 40% in the posttest. The number of teams needing more than one attempt to intubate successfully fell from 14 to 7. Both were not significant. There was, however, a significant reduction in the time the intubation attempt took and the duration of the entire intubation process. Furthermore, there was a significant improvement regarding chest compressions (CC). Less teams failed to start CC before attempting intubation and the number of teams that performed adequate CC during the intubation attempt and resumed CC immediately after intubation rose significantly. We could not find any effect of the training on the evaluation of the critically ill child. Regarding the comparison of teams from hospitals with and without a PICU, we found that apnea was noted significantly earlier by the teams from hospitals with a PICU than by those from a hospital without. Initial ventilation was begun on average approximately 10 seconds earlier by the teams from hospitals with a PICU, but this was statistically not significant. CC were interrupted significantly less frequently for the benefit of intubation by teams for a hospital with a PICU and there was a significantly lower number of teams, which had not started CC before attempting intubation in this subgroup. We could find a slightly higher intubation rate among the teams from hospitals with a PICU, but it decreased equally as the rate of the teams from hospitals without a PICU. The effect the training had on the choice of equipment seemed to be less strong in the subgroup of PICU teams. In the pretest, the choice of equipment by non-PICU teams was already more accurate. In the posttest, even more teams of the non-PICU subgroup selected the adequate size of bag and mask. The teams from the PICU subgroup, however, did not improve. Overall, we can state, that we found evidence, that simulation-based training can have an influence on airway management during simulated pediatric resuscitations. Even though we could not find a significantly higher number of teams, that kept up bag mask ventilation throughout the entire course of the resuscitation, significant improvements of the ventilation could be seen. The choice of equipment improved in the posttest, which would lead to a higher quality of ventilation in the real patient. Unfortunately, there was no significant reduction in the intubation rate, but, as with the bag mask ventilation, significant improvements of the process were seen. The average duration of each intubation attempt sank below 30 seconds, which is the upper recommended limit in the guidelines. And the choice of equipment improved here, too. The documented reduction in pauses of CC after training lead to a significant decrease in the no-flow-fraction, from which a patient would greatly benefit. This study is a pilot project. The simulation-based training was not especially intended to modify airway management during resuscitation, which could explain why there were only few significant changes. But since this study suggests that a modification is possible, further studies should be attempted.