A key competency for all health-care workers (HCWs) who care for children is the ability to respond to a child in respiratory or cardiorespiratory arrest. However, evidence suggests that medical and nursing staff may not have the knowledge and clinical skills to respond to these emergencies. The aim of this project was to create a standardised, evidence-based, paediatric life support course that would be available free to all HCWs in New South Wales (NSW), including NSW Ambulance.
A paediatric life support course was designed along current education principles. It used e-learning as pre-learning and a face-to-face short practical course, combining team work and communication with practical paediatric resuscitation skills training. The programme was designed to empower local trainers to deliver a standardised course to local participants.
A total of 14 000 participants have completed the mandatory e-learning component, and over 8600 participants have completed the short practical course, across all NSW Local Health Districts, including NSW Ambulance. RESUS4KIDS has also been adopted by the universities of Sydney and Newcastle undergraduate medical and nursing programmes. Outside of NSW and ACT, over 400 participants have completed the course in facilities in Queensland, South Australia, Victoria and the Northern Territory.
We have developed a course that is available, at no cost to individuals or facilities, to all HCWs in NSW, including students, paramedics and general practitioners. We would encourage all other jurisdictions to consider adopting the programme.
The ability to resuscitate a collapsed child should be a core competency for all health-care workers that care for acutely unwell infants and children.
Health-care workers may not be trained to an adequate standard.
Current paediatric life support courses are either non-standardised or can be prohibitive because of financial or staffing costs.
What this paper adds
A well-established, standardised, easily accessible, cost-effective and time-effective paediatric life support course is now available to all facilities in New South Wales.
The programme is also available to facilities in other states and territories.
A sustainability plan is required to ensure the program continues.
A key competency for all health-care workers (HCWs) who care for children is the ability to respond to an infant or child in respiratory or cardiorespiratory arrest. However, evidence suggests that medical and nursing staff may not have the knowledge and clinical skills to respond to these relatively uncommon emergencies.[1-5]
Both in hospital and out of hospital, paediatric cardiorespiratory arrests are rare events.[6-11] Although uncommon, it is essential that HCWs are appropriately trained so they can respond immediately, leading to better outcomes.[6, 12, 13] If an infant or child receives immediate treatment, it may prevent them from deteriorating further. For instance, an infant with severe bronchiolitis may have a respiratory arrest and become hypoxic and bradycardic. Immediate recognition and intervention can reverse the hypoxia and bradycardia and prevent the child developing a full cardiac arrest.
The responsibility for being trained in paediatric cardiopulmonary resuscitation (CPR) rests both with the employer and the employee. Individuals have a personal responsibility to seek out training when they identify they have an important knowledge gap. Health-care organisations have a responsibility to both staff and patients to ensure that HCWs have access to appropriate training. In Australia standard, nine of the National Safety and Quality Health Services Standards deals with recognising and responding to clinical deterioration in acute health care. It requires organisations to ensure that the clinical workforce is trained and proficient in basic life support (BLS) and that there is access to clinicians with advanced life support (ALS) skills.
Within New South Wales (NSW), the availability of paediatric CPR training has been variable and dependent on where HCWs worked and what position they held. The two major CPR courses, advanced paediatric life support and paediatric life support, are financially relatively expensive to attend and take participants and instructors away from their workplace for 1–3 days. In 2008, the Child Health Network Clinical Nurse Consultants identified to NSW Health the issue of a lack of a standardised, time-efficient, low-cost, locally delivered paediatric CPR course in NSW.
The aim of this project was to create a standardised, evidence-based, paediatric life support course that would be available free to all HCWs in NSW, including NSW ambulance. The course would have to be time efficient to enable participants and instructors to be released from their normal duties to attend, available locally at ward and unit level, especially at rural sites, and be able to be delivered by a variable education workforce. Funding was provided by the NSW Child Health Networks.
CPR and education theory
A review of the education literature reveals that CPR competency follows the model of Bloom's taxonomy quite closely, encompassing the classic knowledge, attitude and skills structure of cognitive, affective and psychomotor domains. Honey and Mumford have described four distinct learning styles: activist, theorist, pragmatist and reflector, and Fleming has identified four types of learners: visual, auditory, reading/writing and kinaesthetic. All these styles and domains need to be combined in designing a novel paediatric CPR course. In addition, Knowles has described important characteristics of adult learners that should be considered when designing educational material. Adults learn best when they understand why they need to undertake the learning activity and why they need to view the learning as relevant to their role. Course design should acknowledge previous life experience and that participants come with prior skills and knowledge and learners should be treated with respect.
Using manikins to simulate patients in cardiorespiratory arrest has been a standard practice for many years. Manikins can be used to simulate isolated clinical skills, such as bag and mask ventilation, or as part of a scenario to care for a simulated patient. Simulation is supported by the theory of Kaufman, where students are engaged by teachers in an active way using group interaction and relevant problems to improve their knowledge, skills and attitudes.
Simulation modality is further supported by Kolb's learning theory where participants move through the cycle of concrete experience, reflective observation, new understanding and active experimentation within a new concrete experience.
Prior to the start of this project, the Children's Hospital at Westmead (CHW) had already identified a gap in the provision of consistent CPR training similar to the Network Clinical Nurse Consultant and had designed a two-part programme using e-learning as pre-learning in order to shorten the face-to-face teaching time. The e-learning alone had been shown to increase the ability of doctors, nurses and medical students to resuscitate a simulated infant in cardiac arrest.[22, 23] This e-learning package was adapted to form the basis of the pre-learning for the RESUS4KIDS course. The advantage of e-learning is that it can shorten the face-to-face time by providing knowledge in a flexible format at a time convenient to the participant and is able to be structured to appeal to all the learning styles and types of learners. All participants will then attend the practical component with a minimum knowledge base.
It is now well established that individuals do not function independently in medical emergencies. Even if individuals are highly trained professionals, they need to be able to function as part of a team in order to care for patients. Standard 9.6.1 of the National Safety and Quality Health Services Standards states ‘Improving non-technical skills such as leadership, teamwork, task management and structured communication is also recommended to help improve patient care and the performance of resuscitation providers’. It was therefore decided that a proportion of the face-to-face session should contain non-technical skills training. The use of a simple interactive game and two interrelated videos enables the learning objectives described in Figure 1 to be achieved.
The Australian Resuscitation Council is quite clear in guideline 12.1 that within a health-care setting (which includes an ambulance), HCWs using equipment and drugs constitute ALS, and that BLS is resuscitation without equipment or drugs. RESUS4KIDS adopted this consensus, and the programme focused on training HCWs to provide BLS and ALS in a health-care setting with the use of equipment and drugs. To avoid confusion with community BLS programmes, the programme was called RESUS4KIDS – Paediatric Life Support for Health-care Rescuers and used guideline 12.1 as the basis for the content of the course. It was decided to use a pause-and-discuss scenario-based teaching format in order to follow the recommendations of Kaufman in engaging the participants and Kolb to enable participants to undertake active experimentation and generate new concrete experiences within the one session. As part of the course development, a participant manual, instructor manual, resuscitation flowchart and governance document were produced. To support additional learning, optional e-learning modules were designed (Fig. 1).
The original e-learning was developed at CHW with a private donation from ACCO Australia and support from the Bulkeley fund for around $40 000. Since then, RESUS4KIDS has been supported by NSW Health and NSW Kids and Families to a total of $2m and a small grant from Laerdal Australia. The majority of expense has been on staff costs (funding educators in each local health district (LHD) to deliver the programme), equipment, and further e-learning and IT infrastructure to support the programme.
In order to facilitate the course being taught at local sites, particularly rural, by local trainers, a pyramidal educator structure was used. Initially, a single chief trainer taught selected super trainers who then taught local trainers how to teach the short practical course. RESUS4KIDS educators have been employed to implement the programme and are allocated to each LHD in NSW. Trainers also acted as local advocates for the project. Recently, an extra e-learning module was added to the portfolio to remind trainers of course content and learning objectives before they teach the course. The course has been delivered in three phases: Phase 1, January to June 2009, at selected rural and metropolitan hospitals in the Western Child Health Network (WCHN); Phase 2, September 2010 to June 2011, included the whole of the WCHN and selected Northern Child Health Network sites; and Phase 3, July 2012 to present, throughout the whole of NSW and some other jurisdictions on request. A web site was created to facilitate the course promotion and the distribution of resources to trainers: http://www.resus4kids.com.au.
It has been quite difficult to evaluate the effectiveness of the programme as real patient outcomes have many confounding factors. The programme has been evaluated using a mixture of uptake data, before and after studies of the e-learning on doctors, nurses and medical students, long-term knowledge retention on a pilot programme for medical students, self-reported changes in knowledge, confidence and ability in doctors and nurses, and anecdotal feedback from participants who felt the course has aided their care of real patients. These studies combined show an improvement in human factors, knowledge retention and the mechanics of resuscitation for components of the course. Further research is required to demonstrate that the course as a whole improves the provision of effective CPR and or improves the outcomes from paediatric arrests.
A before and after study of the e-learning in a simulated patient showed an improvement in participants' ability to perform BLS by 51% (P < 0.001) and ALS by 57% (P = 0.001) overall resulting in an overall competence of 89% (BLS) and 65% (ALS). There were also significant improvements in time to rhythm recognition (P = 0.006), time to first defibrillation (P = 0.009), and participants' self-reported knowledge and confidence in BLS and ALS (P < 0.001).[22, 23] Figure 2 illustrates the improvements by subgroup.
A pilot course was evaluated using medical students and demonstrated significant objective improvements in student knowledge throughout the course, at course completion and at 8-month follow-up (Fig. 3). Phase 1 was formerly evaluated and showed an increase in participants' self-reported knowledge, confidence and ability to resuscitate a child. The course was also regarded as highly relevant, and 97% (n = 66) felt that they could apply skills learnt to their current clinical roles. The ‘Train the Trainer’ course was evaluated in 2012 and subsequently modified to increase the content on equipping trainers to deliver the human factors component of the course. RESUS4KIDS continues to receive anecdotal feedback from participants who have used skills learnt in the course to help real patients; a video detailing some of these experiences has been created and is available at http://www.resus4kids.com.au.
In order to support the ongoing administration of the programme and to allow ongoing evaluation, both at programme and local levels, RESUS4KIDS has developed a class reporting system. This is an Internet-based system where instructors can register courses, ensure participants have done the e-learning prior to attending the short practical course, and then automatically update the participants' database and email certificates back to participants. There is also a feedback form sent to all participants so individual instructors or facilities can receive feedback on their courses.
As of July 2013, over 14 000 participants have completed the mandatory e-learning component and passed the post-course test the short practical course has achieved uptake in all NSW LHDs to varying extents, with over 8600 participants having completed it (65% nursing, 18% medical, 17% other). RESUS4KIDS has over 750 local trainers and 34 super trainers, at least one in every LHD, including NSW ambulance. Some of the NSW universities have also taken up the programme including the universities of Sydney and Newcastle undergraduate medical and nursing programmes. RESUS4KIDS has been working with the Clinical Excellence Commission in NSW and is now a prerequisite for the Detecting Deterioration, Evaluation, Treatment, Escalation and Communicating in Teams (DETECT) Junior programme focusing specifically on infants and children.
There has been interest from other jurisdictions. RESUS4KIDS is part of the mandatory paediatric resuscitation programme of ACT Health and is running programmes in facilities in Queensland, South Australia, Victoria and the Northern Territory. Outside of NSW and ACT, over 400 participants have completed the course, and there are 42 trainers and two super trainers.
There have been many barriers to implementation. Being a non-mandated course, RESUS4KIDS has strived to appeal to administrators and participants alike. Although being only 90 min in duration, the primary barrier has been releasing clinical staff to attend the course. Other barriers include the lack of LHD executive support for the programme and a misconception that middle grade medical staff does not need this type of training. Integration with the DETECT Junior programme will alleviate some of these issues.
We have developed a course that is available, at no cost to individuals or facilities, to all HCWs in NSW, including students, paramedics and general practitioners.
RESUS4KIDS continues to work at state, LHD, facility and unit level to promote the programme in NSW. A sustained funding model is required. There is an increasing interest from other jurisdictions, and we would encourage all states and territories to adopt the programme at state level for maximum impact.
Funding: The programme has been funded by the NSW Ministry of Health and NSW Kids and Families via the NSW Child Health Networks and with a grant from Laerdal Australia.
RESUS4KIDS would like to acknowledge the contributions of Marino Festa and Kathryn Green to the design, development and introduction of the programme. We would also like to acknowledge all the educators and trainers who have been ‘enthusiastic experts’ and made this programme a success. We would also like to thank Trish Boss (NSW Ministry of Health/NSW Kids and Families) for her support and help with progressing the programme, the CHN Convenors, Elizabeth Koff and Trish Davidson, the other CHN co-ordinators Leanne Crittenden and Margaret Kelly, and the NSW Paediatric Clinical Nurse Consultants.