This document describes a quality improvement project to improve pediatric residents' competence and confidence in assessing and stabilizing adult patients presenting with chest pain or stroke. It involved implementing mock code simulations with debriefing and distributing learning guides. Results showed pediatric residents demonstrated a 34-46% increase in confidence and a 30-41% increase in medical knowledge regarding adult chest pain and stroke treatment. Adherence to checklist items during simulations also increased. The project concluded educational interventions like simulations can effectively address knowledge gaps pediatric providers have in treating adult patients.

1. Adult Mock Codes for Pediatric Residents:
An ACLS Refresher
Team Members:
Taylor Bagwell, MD
Beth Storm, MD
Kim Nelson
Lee Crawley, MS, RRT-NPS
Tonya Thompson, MD
Mentor: Doreen Tooch

2. Background
• Pediatric providers have little experience treating
adults.
• Advanced Cardiac Life Support (ACLS) certification
is not often required of pediatric providers.
• Pediatric emergency department (PED) staff must
stabilize adults prior to transfer to an adult facility.
• Resultant knowledge gaps may negatively impact
care.

3. Background
• ACH ED in 2014:
• 262 patients over the age of 21 were seen
• Chest pain and an acute neurologic change were
the two most common adult presentations

4. Project Aim
Improve pediatric resident competence
and confidence in the assessment and
stabilization of both adult chest pain and
stroke by 25% over a total of 12 months.

5. Measurements
Outcome Measure:
ACH Resident confidence and competence in the
stabilization of acutely ill adult patients with chest
pain and stroke.
Process Measures:
• Pre and post participant surveys- confidence
• Facilitator checklist with key items emphasized -
competence
• Pre and post knowledge based assessment –
competence

6. Interventions
• Tests of Change:
• Implementation of mock codes with debriefing
• Distribution of learners guides prior to mock
codes with encouragement of use during mock
codes
• Case specific pediatric house staff lectures

7. Key Driver Diagram
Project Aim
Key
Drivers/
Processes Design Changes
Improve pediatric
resident
competence and
confidence in the
assessment and
stabilization of
both adult chest
pain and stroke
by 25% over a
total of 12
months.
Opportunity: Pediatric
providers need
dedicated time allotted
for continued training in
adult care.
Education: Pediatric
providers need
continued education
regarding adult care.
Experience: Pediatric
providers need
increased experience in
providing adult care.
Evaluation/Feedback:
Pediatric providers need
to receive feedback and
guidance regarding
adult care.
• Capture all eligible participants
• Arrange dedicated time for learning
about adult care
• Case specific learner’s guides
• Case specific didactics
Adult chest pain and stroke mock
codes
• Pre and post scenario surveys
• Pre and post scenario knowledge
based assessment
• Observer/Facilitator checklist
• Post scenario debriefing/feedback
ACH Resident confidence and competence in the stabilization of acutely ill adult
patients with chest pain and stroke (as determined by self report and observer
scoring).
Measure

8. Results
• Results:
– Overall resident participation averaged 69%
• Regarding chest pain, residents demonstrated a 34%
increase in confidence and a 41% knowledge
increase. Adherence to the complete checklist
increased by 10%. Adherence to key elements
increased by 8%.
• Regarding stroke, residents demonstrated a 46%
increase in confidence and a 30% knowledge
increase. Adherence to the complete checklist
increased by 12%. Adherence to key elements
increased by 15%.

9. Chest Pain Confidence & Knowledge
1. Today’s Date
2. I am a Med/Peds resident (circle one):
Other: ___________________________________________________________
3. Did you read the teaching guide? No Yes
1= Not Confident at All
2= Somewhat Confident
3= Confident
4= Very Confident
1
Not
Confide
nt At
All
2
Somewh
at
Confide
nt
3
Confide
nt
4
Very
Confide
nt
4. I am confident I can perform an assessment on an adult with
chest pain
5. I am confident I can administer medications at the correct
dosages to an adult patient with chest pain
6. I am confident I can perform proper CPR on an adult
7. I am confident I can recognize a STEMI in an adult patient
8. I am confident I can correctly defibrillate an adult patient
9. I am confident I can treat an adult chest pain patient without
causing harm
10
.
I am confident I can give timely and proper information to the
adult receiving facility for an adult patient with a STEMI
11
.
How far do you depress the chest in Adult CPR (insert answer in
the box to the right)?
12
.
What is the initial energy voltage set for an adult patient with
unstable Ventricular
Tachycardia (insert answer in the box to the right)?
13
.
What is the target O2 saturation for an adult chest pain patient
after a return of spontaneous circulation?
14
.
Name a medication specific contraindication to giving nitrates in
adult chest pain patients.
15
.
What drug is indicated for shock resistant VT in adults
41% Average
increase in
knowledge from pre
to post
34% Average increase in
confidence from pre to
post Assessment

10. Chest Pain Knowledge Based Assessment
2/3/2015 3/3/2015 3/17/2015 3/26/2015 4/21/2015 4/30/2015 5/5/2015 5/19/2015 5/28/2015 6/2/2015
Pre Correct 56% 60% 52% 45% 33% 20% 36% 40% 60% 35%
Post Correct 100% 95% 96% 80% 87% 75% 92% 83% 100% 85%
Difference 44% 35% 44% 35% 53% 55% 56% 43% 40% 50%
0%
20%
40%
60%
80%
100%
120%
Pre and Post Knowledge Assessment
Pre Correct Post Correct Difference
41%
average
increase in
knowledge

11. Chest Pain Checklist Results
2 = Done Well
1 = Attempted
0 = Not Done
These scores are averaged from checklists
Complete Checklist Key Item Checklist
3-Feb 3-Mar 17-Mar 26-Mar 21-Apr 30-Apr 5-May 19-May 28-May 2-Jun
1.21 1.41 1.47 1.34 1.67 1.55 1.48 1.48 1.64 1.48
1.60 1.70 1.90 1.70 1.60 1.80 1.80 1.80 2.00 2.00
Complete
Key Item
March 17th – Encouraged use of cognitive aids
April 21st – First course following an unfortunate cardiac event



Desired
Direction
73% Average Adherence 89% Average Adherence
1.21
1.41
1.47 1.34
1.67
1.55 1.48 1.48
1.64
1.48 1.49
1.64
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
1.60
1.70
1.90
1.70
1.60
1.80 1.80 1.80 2.00 2
1.57
1.8
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Averages
Median

12. Stroke Confidence & Knowledge
1. Today’s Date: Symbol:
1= Not Confident at All
2= Somewhat Confident
3= Confident
4= Very Confident
1
Not
Confident
At All
2
Somewhat
Confident
3
Confident
4
Very
Confident
2. I am confident I can identify adult patients with possible stroke.
3. I am confident I can assess possible stroke patients using standardized
abbreviated stroke scales.
4. I am confident I can manage vital sign abnormalities appropriately in an adult
patient with suspected stroke.
5. I am confident I can administer the proper medications/dosages of medications
to an adult patient with suspected stroke.
6. I am confident I can appropriately transfer adult patients with stroke like
symptoms to facilities capable of caring for them.
7. I am confident I can give timely and proper information to the adult receiving
facility for an adult patient with a suspected stroke.
8. I am confident I can treat an adult with stroke like symptoms without causing
harm.
9. What are the elements of the Cincinnati Prehospital Stroke Scale?
10. Why is the last known well time important?
11. Why is checking glucose important in adult stroke patients?
12. Name three contraindications to giving fibrinolytics in adult stroke patients.
13. What is important to remember about hypertension in adult stroke patients?
14. This simulation was helpful in enhancing my confidence in treating Adults with
stroke like symptoms (circle one)
1
Not At All
2
Somewhat
3
Helpful
4
Very Helpful
15. Will you change the way you treat an Adult patient with stroke like symptoms for
the better due to something you learned in this simulation
No Yes
16. Suggestions for improvement:
30% Average increase in
knowledge from pre to post
Assessment
46% Average increase in
confidence from pre to post
Assessment
97% of participants stated he/she would change
the way he/she treated an adult patient with
stroke like symptoms for the better due to
something you learned in this simulation?

13. Stroke Knowledge Based Assessment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
7/21 7/30 8/4 8/18 8/27 9/1 10/6 10/20 10/29 11/3 11/17 12/15
Pre 36% 35% 35% 37% 63% 35% 56% 37% 60% 40% 38% 39%
Post 80% 75% 80% 80% 90% 75% 72% 53% 77% 60% 58% 76%
Difference 44% 40% 45% 43% 27% 40% 16% 17% 17% 20% 20% 37%
Pre and Post Knowledge Assessment
Pre Post Difference
30%
average
increase in
knowledge

14. Stroke Checklist Results
1.39
0.77
1.39
1.27
1.41
1.34
1.39
1.5
1.39
1.77
1.36
1.64
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Complete Checklist
2 = Done Well
1 = Attempted
0 = Not Done
These scores are averaged from the checklists
1.71
0.86
1.29
1.27
1.71
1.57 1.50
1.79
1.86 1.86
1.57 1.57
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
Key Item Checklist
Desired
Direction
Averages
Median
October 6th – Encouraged use of cognitive aids
21-Jul 30-Jul 4-Aug 18-Aug 27-Aug 1-Sep 6-Oct 20-Oct 29-Oct 3-Nov 17-Nov 15-Dec
Complete 1.39 0.77 1.39 1.27 1.41 1.34 1.39 1.5 1.39 1.77 1.36 1.64
Key 1.71 0.86 1.29 1.27 1.71 1.57 1.5 1.79 1.86 1.86 1.57 1.57
73% Average Adherence 78.5% Average Adherence

15. Conclusions
• Conclusions:
• Limitations exist in the pediatric care provider’s
assessment and stabilization of acutely ill adults.
• Knowledge gaps are amendable to educational
intervention.
• Participation in simulation based mock codes is
beneficial.
• Use of cognitive aides and didactic sessions
appear to enhance performance.

16. Barriers and Lessons Learned
• Loss of eligible participants:
• Course cancellation – weather, unavoidable
events/conflicts
• No shows – chief residents arranged make up mock
codes
• Participant and facilitator by in affects quality of
experience
• Standardization of simulation experience
necessary
• Standardization of facilitator training,
expectations, and scoring systems necessary

17. Next Steps
• Continue developed educational process and
expand to other areas of identified weakness.
• Implement retention mock codes on
previously covered topic for maintenance of
competence/confidence.

18. The End
Thank you!
Questions?