Bridging the knowledge-resuscitation gap for children: Still a long way to go

Abstract

The American Heart Association, along with the International Liaison Committee on Resuscitation, recently made changes to the paediatric resuscitation guidelines.

Knowledge translation (KT) is imperative, but there is a lack of sufficient evidence for appropriate methodologies for implementation of these guidelines. Paediatric resuscitation presents many challenges; cases happen infrequently, affording few opportunities for implementation of the new guidelines, and are highly stressful and filled with uncertainty. Some KT strategies have shown some success in causing a notable degree of change in behaviour, but none have shown a striking difference when used alone.

Previous efforts to disseminate current guidelines centred on development of courses for health care providers and preparing paediatric residents and paediatricians for circumstances they could encounter with paediatric acute illness. None of the studies assessing these techniques measured direct patient outcomes, and only a few demonstrated some long-term knowledge acquisition among trainees. The purpose of the present review was to illuminate the challenges, offer future directions for KT and outline potentially more effective methodologies and strategies to overcome current barriers.

L'American Heart Association, conjointement avec le Comité de liaison internationale sur la réanimation, a récemment apporté des modifications aux lignes directrices sur la réanimation en pédiatrie.

Le transfert des connaissances s'impose, mais on ne possède pas assez de données probantes sur les méthodologies pertinentes pour implanter ces lignes directrices. La réanimation en pédiatrie s'associe à de nombreux problèmes : les cas sont peu fréquents, laissant peu d'occasions pour implanter les nouvelles lignes directrices, ils sont très stressants et associés à de nombreuses incertitudes. Certaines stratégies de transfert des connaissances ont permis de susciter un changement marqué de comportement, mais aucune de ces stratégies n'a changé grand-chose lorsqu'elle était utilisée seule.

Les mesures antérieures en vue de diffuser les lignes directrices à jour étaient axées sur l'élaboration de cours à l'intention des dispensateurs de soins et sur la préparation des résidents en pédiatrie et des pédiatres à des situations possibles en présence d'une maladie aiguë en pédiatrie. Aucune des études portant sur ces techniques ne mesurait les issues directes sur les patients, et seulement quelques-unes s'associaient à une certaine acquisition à long terme du savoir chez les stagiaires. La présente analyse vise à mettre en lumière les problèmes, à offrir une orientation en matière de transfert des connaissances et à souligner des méthodologies et des stratégies au potentiel plus efficace pour vaincre les obstacles actuels.

Approximately 25% to 30% of all visits to emergency departments (EDs) are made by ill or injured children (1,2), and almost 85% of visits occur in general or community hospitals (1–4). Of all paediatric visits to EDs, 1% to 5% of patients are critically ill children who require cardiopulmonary resuscitation (5,6). Unlike adults, children rarely present with cardiac arrhythmia or full cardiac arrest. Most critically ill children present in respiratory distress or in shock and impending cardiorespiratory arrest. In a Philadelphia (USA) study (7) of 80,000 children visiting the ED, only 200 children needed resuscitation, 58% needed endotracheal intubation, 30% needed resuscitation drugs and only 2% needed defibrillation or cardioversion.

The relatively infrequent incidence of paediatric resuscitation in general EDs, coupled with the health care provider's anxiety and the need for an immediate and effective response team, often leaves health care providers such as paramedics and physicians with little confidence in their ability to care for these children (7,8). The relatively new subspecialty of paediatric emergency medicine (PEM) aims to optimize paediatric resuscitation and implement guidelines for paediatric resuscitation. The provision of courses, such as the Pediatric Advanced Life Support (PALS) and the Advanced Pediatric Life Support, only began in the late 1980s.

CURRENT RESUSCITATION GUIDELINES

Over the past decade, the International Liaison Committee on Resuscitation (ILCOR) (9) published substantial new guidelines in paediatric resuscitation. For example, a prospective randomized controlled trial (10) confirmed that routine use of high-dose adrenaline was not beneficial and may actually increase rates of morbidity and mortality. In 2005, due to the above trial results and other recent findings, the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations made significant changes to the 2000 recommendations for paediatric resuscitation (11,12). Some of the most important changes included are outlined in Table 1.

CHALLENGES IN KNOWLEDGE TRANSLATION

Knowledge translation (KT) is not just an issue in paediatric resuscitation. There is a gap between ‘evidence-based knowledge’ and adherence to guidelines in current practice in many areas (13–16). A recent Cochrane Effective Practice and Organisation of Care Group review (17) found a lack of sufficient evidence for appropriate methodologies for implementation of guidelines. The reviewers suggested that more comparisons and better data analysis methodologies are needed to define effective ways for translation of the available knowledge.

Traditional continuing education strategies and professional development approaches have not been able to bridge the gap of translating knowledge into action (17–19). Currency of knowledge, level of education and age have been shown to be predictors of change (20,21). In a recent systematic review (22) of 235 studies with 73% comprising multifaceted interventions, most trials observed modest to moderate improvements in patient care. Most studies used process measures for their primary end point, despite the fact that only three guidelines were explicitly evidence based. The authors concluded that there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances, and called on decision makers to use considerable judgement on how best to use the limited resources they have to maximize population benefits.

KT and knowledge brokerage strategies

While some KT and knowledge brokerage strategies have shown some degree of change in behaviour, especially among physicians, none have shown a striking difference when used alone (23).

A review (24) of 32 studies, with almost 3000 health professionals, found didactic teaching to be ineffective, interactive workshops to be moderately effective and combining workshops with didactic learning also moderately effective. Conferences using didactic methods and thus limiting hands-on and interactive learning (25) were also shown to have a very limited effect. Oxman et al (25) reviewed 102 trials and found that conferences or mailing of unsolicited materials demonstrated little or no changes in health professional behaviour or in health outcome when used alone.

High-quality reviews (15,24,26) have addressed different clinical outcome measures, mostly in relation to writing prescriptions. Davis et al (15), reviewed 14 randomized controlled trials of formal didactic and/or interactive continuing medical education interventions. Nine of 17 interventions generated positive changes in professional practice, and three of four interventions altered health care outcomes in one or more measures. However, no significant effect of these educational methods was detected (standardized effect size 0.34; 95% CI −0.22 to 0.97). Interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size 0.67; 95% CI 0.01 to 1.45). In a subsequent Cochrane review (24), the same group reported that six of 10 interactive workshops had moderate or moderately large effects on practice, and four of 10 had small effects on practice (only one of four was statistically significant).

Audit and feedback in three Cochrane reviews (27–29) have shown very limited change in practice. In a recent review (30) of 72 studies with 88 comparisons, audit and feedback were found to have only small to moderate effects in improving professional practice. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.

Outreach visits to actual practices (31) and the use of opinion leaders (32,33) were shown to have a much larger effect on physician behaviour. In a review of 18 randomized trials (34), outreach with written material improved KT over no intervention when multiple outcomes (general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization) were investigated. Social marketing strategy served as an adjuvant to prescribing (25,31,34–36).

No current studies describe the degree of maintenance of such changes, and it is unclear how often and in what way efforts should be made to enhance and maintain KT. While each KT and knowledge brokerage strategy had some effect on learning, a combination of strategies is better than any single approach (14,19). Nevertheless, more complex interventions were reported to range from ineffective to highly effective (25).

Specific barriers to KT in resuscitation

Resuscitation is a unique environment unlike any other in medical practice. The environment is extremely stressful. The stress of ‘life and death’ during resuscitation is unavoidable, and routine tasks can become more complex during an emergency because these tasks need to be carried out faster despite greater technical difficulty and clinical uncertainty (37). Stress can impair motor and cognitive functioning, and has been associated with increased medical errors, inappropriate work behaviours and conflicts. Moreover, information exchanged may be more likely to be misunderstood. One study (38) from an intensive care unit environment reported that poor or reduced communication between team members can result in mistakes. Although communication between doctors and nurses accounted for only 2% of total activities, communication difficulties were responsible for 37% of the errors, and these could result in the death of a patient. Second, resuscitation is a situation filled with uncertainty. Many times the health care providers are relying on unclear or unavailable history, have limited ability to examine the patient and have to make decisions quickly before a full history and physical examination is completed.

KT strategies for resuscitation

There are currently no studies on the adoption of new ILCOR guidelines or on the effect they have on changing practice, morbidity or mortality of children. It is also unknown how the dissemination of this new ILCOR information will be conducted. Previous efforts to disseminate resuscitation knowledge concentrated on development of courses for health care providers and preparing paediatric residents and paediatricians for paediatric acute illness. Newer techniques have been developed over the years (Table 2).

Resuscitation courses: Several intensive courses in resuscitation were designed for adult care and then for children. The PALS course was the first course and was initiated in 1988 (39). These intensive courses comprise a knowledge section presented as didactic lectures, sometimes with the addition of workshop discussion groups, teaching of specific skills designed to promote adult learning (40) and scenario practice sessions. The latter involves the simulated resuscitation of a child or baby using a mannequin and equipment, and requires the candidate to integrate the knowledge and skills learnt on the other portions of the course. At the end of each course, there is an examination, usually comprising a multiple choice examination and demonstration of key skills.

However, these courses are expensive, often a one-time intervention with the learners, provided mostly in a centralized location such as in few academic centres and are rarely taught in the facility where the health care provider resuscitates children. Furthermore, many general practitioners and community-based paediatricians are not mandated to take these courses or to have their knowledge refreshed on a regular basis, and many will only need basic life support courses to maintain their privileges in the hospital in which they work (and potentially resuscitate children in).

There is also significant difficulty in determining whether these courses truly help in the KT process and enhance better outcome for children (41,42). In a Canadian report (43) of 17 studies examining all resuscitation courses (adult and paediatric), Advanced Trauma Life Support training was thought to somewhat improve outcomes such as morbidity and mortality. However, five studies (43) showed no improvement in knowledge and eight showed no improvement in skills retention.

In one paediatric study (44) from Baltimore, Maryland (USA), 45 housestaff trained in PALS were generally able to reach the end point of four key resuscitation skills but showed poor performance for the specific subcomponents of each skill and prolonged time to skill completion. In another study from Seattle, Washington (USA), after a PALS course, successful performance improved for bag mask ventilation from 62% to 97%, for successful endotracheal intubation from 64% to 90%, for successful intraosseous needle placement from 54% to 92%, and for successful defibrillation from 77% to 97%. However, these findings represent skills immediately after completion of the PALS course (45).

Training paediatricians (residency): Like many other competencies, it is important to teach resuscitation skills during residency. In one survey (46), 90% of senior paediatric residents said that they understood the importance of resuscitation knowledge and skills. Graduates of a paediatric residency in Arizona (USA) and Philadelphia were confident in their ability to manage paediatric emergencies according to two surveys (46,47). However, when the latter group was examined, none of the senior residents were able to successfully perform both basic and advanced airway skills, and only 11% successfully completed two vascular skills.

In the United Kingdom, a 1992 survey (48) of 88 junior paediatricians found poor knowledge in resuscitation with only 9% having had training in PEM. In a later survey (49), only 26% of 57 training physicians provided satisfactory answers to questions about cardiac arrest protocols. This was despite the fact that one-third had training in PEM.

Cappelle and Paul (50) enrolled a group of residents to participate in an average of three mock codes. Those receiving mock codes reported significantly more confidence in conducting medical codes and performing certain lifesaving skills.

Teaching in inpatient units: Paediatric mock codes have been used to increase the emergency preparedness of inpatient medical units for several decades. The use of mock codes and simulated resuscitation drills involving a mannequin were reported in the medical literature to increase skill performance and decrease anxiety during actual medical emergencies (51).

Paediatricians' office resuscitation teaching: Paediatric offices are ill-prepared for medical emergencies (52–55). In a 1989 study (52) from Pittsburgh (USA), the mean overall preparedness score was 53.7 of a possible 156 (range five to 136, SD=31.3). In a 1996 study (53) from Boston (USA) describing preparedness in 51 paediatric practices, it was reported that the participants saw more than 2400 emergencies each year in paediatric offices, with a median of 24 emergencies per practice annually (53). Of all eligible staff, only 14% were certified in basic life support and 17% in PALS. The perception of office paediatricians was that emergency preparedness is difficult to achieve because practices are too busy and the expense and time commitment are too great.

In a randomized controlled trial (54) with 39 practices, an intervention that included an unannounced mock code resulted in developing written office protocols (60% versus 21% in intervention and control, respectively) and staff training in basic life support, PALS and advanced life support (118 versus 54). There were no significant differences in the purchase of new equipment or medications. Ninety per cent of the intervention practices rated the intervention as useful for their practice, and 95% believed that the program should continue (54).

In a recent study, Toback et al (55) showed that as a result of a 1 h didactic program and a 10 min to 15 min mock code exercise in a primary care office setting, 83% of all participants, both medical and nonmedical staff, and 96% of physicians felt less anxious about medical emergencies in the office.

Simulation of resuscitation: Simulation is a relatively new technique to overcome barriers in providing the stressful experience for health care teams. Simulation was developed to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner (56). It seems that human patient simulators are advantageous over other modalities because of their realistic recreation of critical events; however, there are no studies to show conclusively that simulated learning improves patient outcome (57). The innovative use of simulation is described in detail by Cheng et al (58) in this issue of Paediatrics & Child Health.

Other techniques: Several other techniques have been studied to enhance KT: recertification in paediatrics and PEM (in the United States), journal clubs, online resources (funded by associations or industry) and team-based learning activities to augment ability to collaborate during resuscitation.

SUMMARY

Despite significant efforts to disseminate world-authorized protocols for resuscitation in children, KT processes need to be more effective to enhance the chances of survival in extremely sick and injured children. The knowledge-resuscitation gap in paediatric resuscitation is still in need of a…. resuscitation.

REFERENCES