Identification of Barriers to Pediatric Care in Limited-Resource Settings: A Simulation Study

Abstract

OBJECTIVES: Eighty percent of the 10 million annual deaths in children aged ,5 years in developing countries are estimated to be avoidable, with improvements in education for pediatric emergency management being a key factor. Education must take into account cultural considerations to be effective. Study objectives were: (1) to use simulation to identify factors posing barriers to patient care in limited resource settings (LRS); and (2) to understand how simulations in LRS can affect communication and decision-making processes.METHODS: A qualitative study was conducted at 17 different sites in 12 developing countries in Asia, Latin America, and Africa. Data from observations of 68 in situ simulated pediatric emergencies were coded for thematic analysis. Sixty-two different "key informants" were interviewed regarding perceived benefit of simulations.RESULTS: Coding of observations and interviews yielded common themes: impact of culture on team hierarchy, impact of communication and language barriers on situational awareness, systematic emergency procedures, role delineation, shared cognition and resource awareness through simulation, logistic barriers to patient care, and use of recognition-primed decisionmaking by experienced clinicians. Changes in clinical environments were implemented as a result of simulations.CONCLUSIONS: Ad hoc teams in LRS face challenges in caring safely for patients; these include language and cultural barriers, as well as environmental and resource constraints. Engaging teams in simulations may promote improved communication, identification of systems issues and latent threats to target for remediation. There may be a role for training novices in use of recognition-primed or algorithmic decision-making strategies to improve rapidity and efficiency of decisions in LRS. WHAT'S KNOWN ON THIS SUBJECT:Previous studies in limited resource settings have demonstrated that multidisciplinary team training in simulated trauma and newborn resuscitations improves team performance and resuscitation knowledge and, in some cases, reduces patient mortality regionally in some developing countries. WHAT THIS STUDY ADDS:In situ simulation in limited resource settings identified latent threats to effective pediatric patient care and provided a vehicle to develop shared mental models among multicultural and multidisciplinary teams, despite cultural differences in conceptualization of leadership and emergency decision-making.

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India

“…Additional recommendations related to increasing group participation and including doctors in both simulations and debriefs. A previous study in Bihar similarly suggested that inclusion of doctors in simulation training leads to improved communication and reduced hierarchy in PHCs [43]. This is consistent with previous studies in Rwanda and Kenya that highlighted the importance of teamwork [44] and leadership buy-in, respectively [45].…”

“…This is consistent with previous studies that have recommended adaptation of debriefs to fit the environment and skill level of trainees [12]. Acceptability of this flexible approach to debriefing is critical, as government-run PHCs in India often face severe human resource shortages and, as a result, clinical duties are routinely prioritized over training [24,43]. Additional recommendations related to increasing group participation and including doctors in both simulations and debriefs.…”

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“…Another challenge to teaching these courses is the task of simulating the core critical care concepts of teamwork and collaborative learning in settings where these are not commonly practiced ( 49 ). In some cases, these difficulties may be due to cultural and hierarchical attitudes, but, nevertheless, could hinder training in optimal resuscitation and ongoing care.…”

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“…These types of general guideline-driven interventions with several components have been shown to improve outcomes in emergency care [12,22], but the evidence (especially from clinical trials) for each component of the intervention is lacking. Training staff as teams can also help bring about positive changes in clinical environments and improve communication [23]. But, despite evidence for improved outcomes with protocols and algorithms for care, the study by Nyirasafari et al highlights that their PICU was unable to adopt them, possibly because the unit was new or because of the patient burden combined with limited staff and resources [10].…”