UNC-based training helps MMH Emergency Department staff better prepare for emergencies with children

TROY – The little guy’s name is Monty, and he’s about the size of a preschooler – an average-sized 4- or 5-year-old.

He’s also made of hard plastic, and he gets sick on command.

Monty the mannequin plays an important role in helping the Emergency Department staff at FirstHealth Montgomery Memorial Hospital better prepare for medical emergencies involving small children. He got his name (short for Montgomery) from Jonathan Brower, M.D., Emergency Department medical director and vice president of the hospital’s medical staff.

Dr. Brower heard about the children’s emergency training opportunity that targets small rural hospitals like Montgomery Memorial and suggested that the hospital apply to the UNC Hospitals program for one of the five available CAPE (Critical Access for Pediatric Emergencies) training slots.

“I hoped we would learn a system to help us work better together as a team,” he says, “and to train to be more ready for pediatric emergencies when they present in our emergency department.”

In February, Dr. Brower, Levon Shephard, who is an Emergency Department registered nurse, and education coordinator Michelle Yarboro, also an R.N., spent two days in Chapel Hill learning the latest and best approaches for treating children with life-threatening medical conditions. They brought the techniques back to Montgomery Memorial, where they share the information with other members of the ED staff in monthly training sessions that include simulations – using Monty – of real-life pediatric emergencies.

“These scenarios are very realistic,” Dr. Brower says. “You actively practice performing interventions so they become routine even in the most stressful pediatric emergency.”

The UNC Hospitals training program is based on a 2007 study that found simulation exercises improve how well medical teams perform on certain essential tasks. Before the training, the study found, the average number of basic tasks the teams performed was about 18. With training, it rose to 27.

The key, says Dr. Brower, is communication and teamwork.

“This training teaches the team how to communicate and stresses teamwork during any task, but it works especially well in emergencies,” he says.

The training at UNC Hospitals began with a scenario involving a child having a severe asthma attack and included four other simulations during which teams treated Monty-like mannequins just as they would treat an actual child – ordering actual procedures and prescribing actual medication dosages.

With each simulation, timing, communication and teamwork improved.  “By the end of the day, everything went as clockwork,” Dr. Brower says.

Shephard, Yarboro and Dr. Brower have noticed similar results during the training simulations that began shortly afterward at Montgomery Memorial. Times and responses have improved with every simulation.

“We’re striving for excellence here,” Yarboro says.

Montgomery Memorial is one of 23 Critical Access Hospitals in North Carolina. These small (fewer than 25 beds) rural hospitals provide 24/7 emergency care for their communities, and are likely to be the point of entry to the medical system for critically ill or injured children from the area.

Using federal grant dollars from the N.C. Office of Rural Health and Community Care, researchers from the University of North Carolina at Chapel Hill focused on Critical Access Hospitals when they devised the program that uses TeamSTEPPS training (a teamwork system for improving patient safety) to improve communication and problem-solving abilities.

Dr. Jessica Katznelson, a pediatric emergency physician at UNC Hospitals, is the principal investigator for the simulation project. “You need to treat children differently than adults, because kids have complications adults don’t get,” she says.

Dr. Katznelson and her collaborator, Dr. William Mills, created the CAPE training simulations that incorporate computerized mannequins (like Montgomery Memorial’s Monty) to mimic actual human responses to treatments. They visited Montgomery Memorial on Jan .25 to observe a mock emergency drill during an on-site ED visit.

Since studies have shown that hospital emergency departments are more likely to make mistakes when treating children than when treating adults, the UNC researchers decided to focus their efforts on smaller hospitals whose emergency medical teams often don’t have the expertise or the frequent exposure to pediatric cases to keep their skills sharp.

According to Yarboro, Montgomery Memorial has an advantage in this area over most small hospitals, however. Like the EDs in the two other hospitals in the FirstHealth system, Montgomery Memorial’s emergency department is staffed by rotating physicians from the Sandhills Emergency Physicians (SEP) group. All 23 of them are specially trained and board certified in emergency medicine.

“Some of the other hospitals had very small physician groups involved,” Yarboro says.

Shephard, Yarboro and Dr. Brower use CAPE-developed check lists and surveys when they lead the monthly pediatric mock resuscitations at MMH. Yarboro then forwards the local information to the UNC team, which compares it to data submitted by the four other participating hospitals to pinpoint areas of potential improvement.

Training in their own environment with their own personnel has helped members of the ED staff locate problems that are particular to their own operation. “We’ve identified some things and have already made improvements,” Yarboro says.

Among other criteria, the five small hospitals involved in the current CAPE project were chosen for statewide geographic coverage. The information derived from their training and simulations will be used to create a training model that could be used by North Carolina hospitals of any size or location, however.

The Montgomery Memorial training involves all 14 registered nurses on the Emergency Department team – both day and night shifts – as well as the SEP physicians who cycle through the hospital on rotating schedules.

Ancillary departments such as Cardiopulmonary, Lab and Imaging are also involved in the training and respond just they would to a real pediatric emergency.

“We hope we will be the interchangeable piece of the puzzle,” Dr. Brower says of his emergency physician partners. “Our (response) times will improve no matter what doctor is on staff.”

“No matter what team you’re working with, you’re going to be going through the same TeamSTEPPS,” Yarboro says.