Published September 1, 2018
“Can anyone tell me what went wrong?”
Nurse anesthetist student Kaitlyn Tomeno, clad in dark blue scrubs and perched at a wooden podium next to a large white projector screen, glances around the classroom as she pauses a nurse anesthesia training video demonstrating poor management of pediatric laryngospasm. After a quiet moment, a hand raises shyly at a back corner two-person table.
“The nurse anesthetist notices a problem with Sp02 levels, but fails to communicate that to the surgeon right away.”
Laryngospasm, a spasm of the vocal cords that blocks airflow to the lungs, is an anesthetic emergency that can be life-threatening. Recognizing the increased potential for these kinds of adverse events in pediatric anesthesia, Tomeno and fellow nurse anesthetist student Erin Peruzzini formulated their DNP Capstone Project* with a twofold purpose: to determine if enhanced training and simulation would improve nurse anesthetist students’ competence levels in pediatric anesthesia, and to evaluate the cost-effectiveness of such training.
“Research has shown that young patients, particularly those under 2 years of age, and provider experience are two factors that greatly influence the risk of pediatric adverse events, specifically respiratory related adverse events,” Peruzzini explains. “Children are not small adults. They have anatomical and biological differences that necessitate careful planning and management of anesthetic delivery.”
Another reason to pursue this problem, Peruzzini and Tomeno say, is that research related to simulation in nurse anesthetist education is very limited and is practically non-existent in regards to pediatrics in this area.
Peruzzini and Tomeno’s study consisted of a group of 30 UB nurse anesthetist students who were randomly assigned to a control group or an experimental group. The control group experienced the typical lecture on pediatric anesthesia, while the experimental group participated in an enhanced workshop and simulation. To measure their competency, two blinded independent raters scored the students as they participated in a high-fidelity pediatric simulation in the school’s anesthesia simulation center.
The workshop focused on clinical challenges a nurse anesthetist may encounter with a pediatric patient. These challenges, according to Tomeno, include medical management, technical skills and non-technical skills, which are directly related to clinical competency. Students were introduced to simulation and SimJunior® (a comprehensive, interactive simulator/manikin, representing a 6 year old child) and an overview of basic pediatric knowledge and technical and non-technical skills, ending with two hands-on learning stations Tomeno developed.
“Subjects at station one spent time with pediatric anesthesia equipment,” says Tomeno, “including a variety of masks, oral/nasal airways, laryngeal mask airways, pediatric IV tubing and laryngoscope blades. Here, they practiced calculating equipment types specialized for a pediatric patient.”
Students at this station also practiced inserting airways and bag mask ventilation on two infant-sized manikins.
The second station was a SimJunior® tutorial in the school’s simulation operating room and focused on common pediatric emergencies like bradycardia, laryngospasm and bronchospasm.
“Subjects at this station practiced airway insertion, ventilation, induction techniques and how to manage emergencies.”
The students’ scores were based on two scales: the MEPA Action Checklist Rating Tool (AC) and the MEPA Global Rating Scale (GRS). Tomeno and Peruzzini found that students in the intervention group had significantly higher scores than those in the control group. For example, the GRS score, which ranges from 1.0 (very poor/novice) to 6.0 (excellent/highly expert), on average, was 3.07 (borderline and unsatisfactory) for the control group and 4.87 (between borderline/satisfactory and good) for the intervention group.
“Our data confirmed that the enhanced pediatric workshop was successful in improving student competency scores in pediatric anesthesia simulated practice,” says Tomeno. “We’ve concluded that increased competency scores in nurse anesthesia students can potentially decrease adverse outcomes in pediatric patients.”
Peruzzini found that not only was competency improved, but there are also cost benefits to using a similar workshop and simulation in nurse anesthetist education. By comparing the total cost for the pediatric manikin simulation and workshop to the resulting number of competent students, she determined that competency was not the only improvement – the cost of simulation was reduced by around $6,000 (from about $8,800 to about $2,700).
In addition to cost-effectiveness, Peruzzini examined the amount of time required for the benefits of the simulation to outweigh the cost of incorporating pediatric simulation as part of the curriculum. Costs included items like the manikin, software, supplies and faculty salary.
“The benefit of improved competency was monetized through an evaluation technique called the value of statistical life,” Peruzzini explains. “A dollar value was placed on competency by factoring in the economic value of preventing or effectively managing a laryngospasm.”
By using patient prices from seven hospitals, she determined that – due to factors like increased operating room time, recovery time and hospital stay – a laryngospasm costs, conservatively, north of $4,000.
Adjusting this figure for the competency differences between the control and intervention groups, Peruzzinni calculated a payoff period, where the benefits would outweigh the cost of implementing pediatric simulation into the curriculum.
“As a result of improved competency and increased productive time, we determined that the benefits would allow for yearly repayment of all simulation program expenditures, including a salary for a simulation lab coordinator.”
*Peruzzini and Tomeno’s capstone is titled, “Pediatric Anesthesia Simulation and Competence Scores in Nurse Anesthesia Students: An Experimental Study and Cost Analysis.” Faculty advisors: Nancy Campbell-Heider PhD, FNP-C, CARN-AP and Kristine Faust DNAP, MBA, CRNA
The value of simulation extends far beyond dollars and cents, with both a long term impact of improved competency and better patient care once nurse anesthesia students officially become certified registered nurse anesthetists – there is also an immediate impact on students’ skill enhancement and confidence.
“Students felt better about going to pediatric clinical; they felt more prepared than they did before this experience,” Tomeno says. “That was the most meaningful part for me.”
“I appreciate the value simulation has played in my education,” adds Peruzzini. “It allowed me to evaluate myself and learn from my mistakes in an environment away from judgment. You get a sense of your ability to manage an emergency, lead a team, assess a situation, make decisions and learn from others. These are all necessary skills to become a successful and competent CRNA in independent practice.”
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