e2 47 Kanter RK Regional variation in critical care evacuation needs for children after a mass casualty incident Disaster Med Public Health Prep 2012;6(2) 146 149 48 Foltin GL, Schonfeld DJ, Shannon M[.]
Trang 147 Kanter RK Regional variation in critical care evacuation needs for
children after a mass casualty incident Disaster Med Public Health
Prep 2012;6(2):146-149.
48 Foltin GL, Schonfeld DJ, Shannon MW Pediatric Terrorism and
Disaster Preparedness: A Resource for Pediatricians Rockville, MD:
Agency for Healthcare Research and Quality (AHRQ publication
No 06-0056-EF); 2006.
49 Powell T, Christ KC, Birkhead GS Allocation of ventilators in a
public health disaster Disaster Med Public Health Prep 2008;2:20-26.
50 Ely DM, Driscoll AK, Mathews TJ Infant Mortality By Age at Death
in the United States, 2016 NCHS Data Brief, no 326 Hyattsville,
MD: National Center for Health Statistics; 2018.
51 Christian MD, Sprung CL, King MA, et al Triage: care of the
criti-cally ill and injured during pandemics and disasters: chest consensus
statement Chest 2014;146(suppl 4):e61S-e74S.
52 Kanter RK Would triage predictors perform better than first-come,
first-served in pandemic ventilator allocation? Chest 2015;147(1):
102-108.
53 Johnson EM, Diekema DS, Lewis-Newby M, et al Pediatric triage and allocation of critical care resources during disaster:
northwest provider opinion Prehosp Disaster Med 2014;29(5):
455-460.
54 Schreiber M The psySTART Rapid Mental Health Triage and Incident Management System Center for Disaster Medical Sciences, University
of California; 2010.
55 Eriksson, CA, Foy, DW, Larson, LC: When the helpers need help: early intervention for emergency and relief services personnel In:
Litz BT, ed Early Intervention for Trauma and Traumatic Loss New
York: Guilford Press; 2004:241-262.
Trang 2Abstract: During a public health emergency (PHE) such as a
natural disaster or pandemic, a large number of infants, children,
and young adults may need critical care in order to survive
Dur-ing such an event, the incident command system provides a
framework to support decision-making and coordinate efforts
across affected sites Because pediatric critical care is highly
spe-cialized and because few nonpediatric providers are comfortable
caring for severely ill or injured children, pediatric, neonatal, and cardiac intensive care units represent an essential aspect of patient management during a PHE and should be included within a structured response
Key words: Emergency mass critical care, EMCC, public health emergency, PHE, natural disaster, pandemic
Trang 310
Lifelong Learning in Pediatric
Critical Care
STEPHANIE P SCHWARTZ, LAURA MARIE IBSEN, AND DAVID A TURNER
• The practice of pediatric critical care medicine requires a broad
knowledge base and skill set that necessitates lifelong learning
throughout an intensivist’s career to achieve mastery.
• Based on adult learning principles, education efforts should
emphasize active participation and practice, examples of which
include bedside teaching, procedural training, debriefing, and
simulation.
• Training in critical care medicine should reflect a structured
process that progressively transfers increasing levels of
responsibility for decision-making to the learner.
• Entrustable professional activities describe an ability to perform
a task or responsibility without direct supervision once
PEARLS
sufficient competency is attained Milestones provide behav-ioral descriptors that indicate developmental progression along competencies.
• Continuing medical education and maintenance of certification programs are working together to incorporate adult learning principles.
• The mature clinician reflects on one’s daily medical experiences to place them in a larger context of previous encounters and critically evaluates one’s own performance, acknowledging both effective and ineffective aspects of patient care.
Pediatric critical care medicine (PCCM) is a discipline dedicated
to the care of the critically ill child, focusing on the sick child as
a whole and including the impact of disease on all organ systems
In addition, pediatric intensivists must address and understand
the physical, mental, and emotional needs of the child and the
child’s family The complex needs of the critically ill child also
require that intensivists be prepared to assume a leadership role in
the coordination of care among team members from multiple
disciplines The pediatric intensivist must develop an
understand-ing of the ethics of critical care medicine and be able to balance
complex and high-technology care with humanistic principles
and respect for the patient as a human being The intensivist must
be knowledgeable in patient safety and quality improvement
methodology and lead these efforts in the intensive care unit
(ICU) environment Skills for evaluating medical literature,
clini-cal and/or basic science research, and the ability to teach learners
at different levels and from a variety of disciplines effectively are
also invaluable Development of this complex array of knowledge
and skills begins in medical school, with the goal of mastery over
the course of an individual’s career Becoming a master in the
specialty of pediatric critical care hinges on lifelong learning,
which implies that the described individual has a voluntary
inter-est in self-development and learning for the sake of learning This
enjoyment associated with learning is thought to be moldable and
able to be influenced, even developed and promoted through the use of adult learning principles
Adult Learning Theory in Medical Education
Adult learning theory was theorized and modeled by Malcom Knowles in the 1970s.1 He identified six principles of adult
these principles to emphasize that there is not a one-size-fits-all approach to learning For example, the reader might imagine two individuals who purchase a new electronic device Whereas one may take the device out of the box, immediately turn it on, and begin experimenting with its features, the other purchaser may not even remove it from the box before reading the entire instruction manual Adult learning theory celebrates the differences in the approach to learning while making these dif-ferences overt and explicit In designing and implementing curricula and assessments, medical educators may design cur-ricula and evaluations that use these concepts Kolb described effective learning as a progression through a cycle of stages— having a concrete experience, followed by reflection on that experience, leading to information synthesis and future testable hypotheses For those familiar with quality improvement prin-ciples, it is not unlike plan-do-study-act,3 in which small tests
Trang 4CHAPTER 10 Lifelong Learning in Pediatric Critical Care
of change are implemented, observed, and the necessary
modi-fications determined
Building on these principles, a key element of medical
edu-cation is to use learner assessment to drive teaching methods
Stuart and Hubert Dreyfus developed a model of skill
acquisi-tion based on their studies of fighter pilots.4 The Dreyfus
model proposes that skill acquisition is not different from the continuum of human development, with stages of skill acquisi-tion designated as novice, advanced beginner, competent, proficient, expert, and—finally—master The learner needs to acquire certain skills and learn certain concepts at each level; therefore teaching methods have to match the level of
Adult learning is fundamentally different from childhood learning because of the greater depth and breadth of experiences and knowledge on which adults build new experiences.6 , 7 In order
to assimilate new information, adults must be able to integrate new ideas with what they already know, and information that conflicts with this knowledge may not be quickly integrated.8
Adults are self-directed and autonomous They learn best when they are active participants in the learning process and are allowed
to practice newly acquired skills and concepts.7 , 9 As a conse-quence, education for adults is typically most effective when
• BOX 10.1 Knowles Principles of Adult Learning
1 Adults are:
• internally motivated and self-directed
• goal oriented
• relevancy oriented
• practical
2 Adults bring life experiences and knowledge of learning experiences
3 Adult learners like to be respected
TABLE
10.1 Dreyfus and Dreyfus Model of Skill Development Applied to the Development of a Competence in the Subspecialty of Critical Care Medicine
Level of Learning
and Characteristics Examples of Learner Level in Critical Care Medicine Teaching Implications
Novice
Rule driven
Uses analytical reasoning and rules to link cause
and effect
Synthesis of information is based on knowledge ac-quired during residency training
Big picture elusive
First-Year Fellow
Interviews patient and performs a physical exam that is focused on the critical illness May not be able to focus the information on the basis of a differential diagnosis
Does not see the big picture
Teach basic critical care concepts Point out subtle but meaningful diagnostic informa-tion in the history and physical examination Eliminate irrelevant information
Highlight discriminating features and their impor-tance to the diagnosis
Encourage reading about 2 diagnostic hypotheses
at the same time
Advanced Beginner
Sorts through rules and information to decide what
is relevant on the basis of past
experience
Uses analytical reasoning and pattern recognition to
solve problems
Able to abstract from concrete and specific informa-tion to more general aspects of a problem
Second-Year Fellow
Can generate more specific differential diagnosis while obtaining history and physical exam Capable of filtering relevant information to for-mulate a unified summary of the case Can abstract pertinent positives and negatives from the review of systems and incorporate them into the history of present illness
Expose learner to clinical cases proceeding from common to uncommon
Emphasize the use of semantic qualifiers Encourage formulation and verbalization of differential diagnosis and treatment plan Good coaching: help learner become attentive to the meaningful pieces
Competent
Emotional buy-in allows learner to feel appropriate
level of responsibility
More expansive experience tips the balance on clini-cal reasoning from methodical and analytic to
identifiable pattern recognition of common clini-cal problems
Sees the big picture
Complex/uncommon problems still require reliance
on analytical reasoning
Third-Year Fellow
Recognizes common patterns of illness based on previous encounters
Sees consequences of clinical decisions, which leads to emotional buy-in to learning Will methodically attempt to reason through complex or uncommon problems Responsible for decision-making process
Balance supervision with autonomy in decision-making
Hold learners accountable for their decisions
Do not tell learners what to do; ask what they want
to do Critical for learner to see a breadth and depth of patient encounters to construct and store in memory a large repertoire of illness scripts Tip the balance from clinical reasoning to pattern recognition
Proficient
Breadth of past experience allows reliance on pat-tern recognition of illness
Problem solving intuitive
Still needs to fall back to methodical and analytic
reasoning for managing problems because ex-haustive number of permutations and responses
to management have provided less experience
in this regard than in illness recognition
Is comfortable with evolving situations, able to extrapo-late from a known situation to an unknown situation
Can live with ambiguity
Clinical Instructor
Starts to match findings with those encountered
in past experience Data gathering more effective and efficient Sees patient through different lens than the student
Engages in process of clinical reasoning to find the best intervention
Needs to work alongside and be mentored by an expert
Must develop capacity to know ones’ limitations and step back and call on additional resources when stretched beyond one’s capabilities
Trang 568 SECTION I Pediatirc Critical Care: The Discipline
TABLE
10.1 Dreyfus and Dreyfus Model of Skill Development Applied to the Development of a Competence in the Subspecialty of Critical Care Medicine—cont’d
Level of Learning
and Characteristics
Examples of Learner Level
in Critical Care Medicine
Teaching Implications
Expert
Thought, feeling, and action align into intuitive prob-
lem recognition and intuitive situational re-sponses and management
Open to noticing the unexpected
Clever
Discriminates features that do not fit a recognizable
pattern
Assistant Professor
Broad repertoire of illness scripts, based on clini-cal experience that allows immediate action for majority of clinical encounters
Likes to deal with diagnostic dilemmas When presented with diagnostic dilemma, will slow down and look it up
Keep up the challenge Needs ongoing experience and ongoing exposure to interesting and complex cases to avoid compla-cency and to help transcend beyond this level Should be apprenticed to a master who models the skills of the reflective practitioner and a com-mitment to lifelong learning
Master
Exercises practical wisdom
Goes beyond the big picture to that of culture and
context of each situation
Deep level of commitment to the work
Great concern for right and wrong decisions that
fosters emotional engagement
Intensely motivated by emotional engagement to
pursue ongoing learning and improvement
Reflects in, on, and for action
Associate Professor/Professor
The clinician that everyone goes to with problem cases
Recognizes subtle features of a current case reminiscent of cases seen over the years Painstakingly revisits past cases or identifies common thread that will help treat the cur-rent clinical problem
Vision extends beyond individual practice Contributes to bigger context to improvements in the field
Intense internal drive to learn and improve Practical wisdom
Self-motivated to engage in lifelong learning and practice improvement
programs facilitate self-learning with specific goals of acquiring
practical information
Efforts to be inclusive of curricular methods that support adult
learning principles are occurring in undergraduate, graduate, and
continuing medical education Problem-based and small-group
learning, flipped classrooms, and simulation exercises allow many
venues for reaching learners in different ways Didactic learning
remains firmly in place It should be emphasized that no one
method of instruction has been definitively proven to produce
better learning outcomes than another.9–11 Table 10.2 depicts
varied instructional techniques with potential benefits and costs
If assessment truly drives learning, medical educational
curri-cula must be increasingly grounded in the assessment of
knowl-edge and skills acquisition, now defined as abilities (or entrustable
professional activities) and composed of individual competencies
For example, one could consider a teenager first learning to drive
a car The teenager must be competent in many individual areas,
such as knowledge of the laws of the road and the skills of
brak-ing, using turn signals, mirrors, and seatbelts before embarking on
this activity and being entrusted to drive the car Like supervising
a learner performing a technical procedure on a critically ill child,
the trust that a parent affords a child in independent driving is
fluid The teenager may initially receive parental permission for
driving around the neighborhood When demonstrating
respon-sible and safe driving conduct, the teenager may gain parental
trust to drive on the freeway or with friends Likewise, the
gradu-ated autonomy that a supervising intensivist will allow learners in
performing central line placement will vary according to
indi-vidual knowledge and skills, but it is also highly contextual As is
reflected in the 2004 guidelines for critical care medicine training
and continuing medical edition published by the Society for
Critical Care Medicine, training in critical care medicine should
reflect a structured process that progressively transfers increasing levels of responsibility for decision-making and that ensures con-tinued training in practical aspects of care.12
Graduate Medical Education
The landscape of graduate medical education (GME) has dra-matically evolved since its apprenticeship/house officer origins
in the early 1900s In the past decade, increasing scrutiny has been placed on GME, with a specific focus on duty hours In
2011 the Accreditation Council for Graduate Medical Education (ACGME) placed restrictions on duty hours in an effort to in-crease safety for patients and learners based on some data to sug-gest that sleep deprivation and fatigue causes errors, and that alertness and performance vary within different points in the cir-cadian rhythm.13–15 These restrictions undeniably changed the landscape of learning For example, duty hour regulations led to
an increase in the number of times that care of a patient was transferred to a different provider, which prompted educational reform around transitions of care with programs such as I-PASS (illness severity, patient summary, action list, situational aware-ness, and synthesis by receiver).16 Following two large randomized control trials showing noninferiority with regard to patient out-comes and resident satisfaction or well-being,17 , 18 the ACGME issued revised guidelines in 2017, allowing for more flexibility with regard to duty hours and, most importantly, stressing the importance of teamwork, physician well-being, flexibility, and patient safety.19 Along with changes in expectations around hours worked, expectations for GME programs have also evolved to focus more on patient safety, quality, and teamwork, along with the traditional specialty- and subspecialty-specific content that is important for new physicians
Modified from Carraccio CL, Benson BJ, Nixon LJ, Derstine PL From the educational bench to the clinical bedside: Translating the Dreyfus developmental model to the learning of clinical skills Acad Med 2008;83(8):761–767.