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Does Simulation Improve Recognition and Management of Pediatric Septic Shock, and If One Simulation Is Good, Is More Simulation Better?*

Dugan, Mark C. MD; McCracken, Courtney E. PhD; Hebbar, Kiran B. MD, FCCM

Pediatric Critical Care Medicine: July 2016 - Volume 17 - Issue 7 - p 605–614
doi: 10.1097/PCC.0000000000000766
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Objectives: Determine whether serial simulation training sessions improve resident recognition and initial septic shock management in a critically ill simulated septic shock patient, and to determine whether serial simulations further improve resident task performance when compared with a single simulation session.

Design: Prospective observational cohort study with a live expert review of trainee simulation performance. Expert reviewers blinded to prior trainee performance.

Setting: A PICU room in a quaternary-care children’s hospital, featuring a hi-fidelity pediatric patient simulator.

Subjects: Postgraduate year-2 and postgraduate year-3 pediatric residents who rotate through the PICU.

Interventions: Postgraduate year-3 residents as the control cohort, completing one simulation near the start of their third residency year. Postgraduate year-2 residents as the intervention cohort, completing two simulations during their second residency year and one near the start of their third residency year.

Measurements and Main Results: Resident objective performance was measured using a validated 27-item checklist (graded 0/1) related to monitoring, data gathering, and interventions in the diagnosis and management of pediatric septic shock. The intervention cohort had a higher mean performance percentage score during their third simulation than the control cohort completing their single simulation (87% vs 77%; p < 0.001). Septic shock was correctly diagnosed more often in the intervention cohort at the time of their third simulation (100% vs 78%; p < 0.001). Appropriate broad-spectrum antibiotics were administered correctly more often in the intervention cohort (83% vs 50%; p < 0.001).

Conclusions: Simulations significantly improved resident performance scores in the management of septic shock with repetitive simulation showing significant ongoing improvements. Further studies are needed to determine long-term impact on knowledge and skill retention and whether results attained in a simulation environment are translatable into clinical practice in improving bedside care.

1Division of Pediatric Critical Care, Children’s Hospital of Nevada at UMC, Las Vegas, NV.

2Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, NV.

3Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.

4Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA.

5Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Atlanta, GA.

*See also p. 695.

Dr. Dugan performed background research, designed and conceptualized the study, collected data, directed analysis, prepared the article, and approved the final version as submitted. He had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr. McCracken assisted in the study methodology, performed the statistical analyses, developed the figures and tables, reviewed and revised the article and has approved the article as submitted. Dr. Hebbar conceptualized and designed the study, directed analysis, reviewed and revised the article, and approved the article as submitted.

Presented, in part, at the Annual Congress, Society of Critical Care Medicine Annual Congress, San Francisco, CA, January 17–21, 2014 (Validation of Tool) and presented at the 7th International Pediatric Simulation Symposia and Workshops in Vancouver, British Columbia in May 2015 (final data).

The authors have disclosed that they do not have any potential conflicts of interest.

Dr. Dugan is the corresponding author for this article; he has since changed institutions and is now a faculty member at Children’s Hospital of Nevada at UMC, University of Nevada School of Medicine. All research was completed at Children’s Healthcare of Atlanta and Emory University in Atlanta, Georgia., For information regarding this article, E-mail:

©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies