Effects of in Situ Simulation-based Team Training on Clinical Performance During Pediatric Cardiac Arrest: An Intervention Study Comparing Two Danish Regions
Phase: NA
Conditions: Medical Education, Simulation-based Training, In-hospital Cardiac Arrest, Pediatrics, in Situ Simulation
Sponsor: University of Aarhus

 
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Project title: 
Effects of in situ simulation-based team training on clinical performance during pediatric 
cardiac arrest: An intervention study comparing two Danish Regions. 
 
2024/06/18 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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BACKGROUND AND AIMS 
Treating critically ill newborns and children is a challenge in pediatric departments [1]. The rare 
encounter with critically ill pediatric patients results in limited experience and a lack of routine for 
each healthcare professional (HP)[2]. Numerous studies document that emergency treatment of 
pediatric and neonatal patients often fails to meet standard guidelines for treatment [3][4][5][6]. A 
sentinel event alert from 2004 showed that ineffective communication played a role in nearly three-
quarters of neonatal deaths or permanent disabilities [7]. Furthermore, a recent study identified a 
lack of training in pediatric resuscitation skills in Danish hospitals [8]. Accordingly, these factors 
are major issues challenging the treatment provided for pediatric in-hospital cardiac arrest (pIHCA). 
 
Outcome and survival in critical situations depend on how HPs use technical skills and teamwork 
competencies [9][10][11]. Simulation-based team training (SBTT) is a well-known and effective 
method to improve team performance in high-stake and time-sensitive situations, without putting 
actual patients at risk [12][13]. SBTT develops leadership, teamwork, and communication, and 
mastering such teamwork competencies is shown to improve outcomes and survival in critical 
situations [14][15][16]. However, retention of achieved competencies is a major challenge, but 
recent observational studies demonstrated improved technical pediatric basic life support skills after 
short simulation sessions with a high frequency of repeat [17][18]. The HPs in these studies are 
however limited to selected groups and tests are performed exclusively on skill stations. Further, a 
recent review of optimal simulation training methods concludes that more high-quality research 
comparing training effectiveness is needed [19]. 
 
We therefore aim to investigate the effects of a novel high-frequency training program on teamwork, 
team effectiveness, and treatment quality during in-situ simulated pediatric in-hospital cardiac 
arrest. In the intervention group, healthcare professionals will conduct high-frequency simulation-
based team training (four training sessions in one year, approx. three months apart). The control 
group will conduct simulation-based team training ‘as usual’ at a two to three times lower frequency 
(based on unpublished data). 
We hypothesize that high-frequency training will affect primary outcomes as specified: 1) Improve 
teamwork competences, 2) Reduce time (seconds) to recognition of cardiac arrest, 3) Reduce time 
(seconds) to initiation of cardiopulmonary resuscitation, 4) Reduce longest chest compression pause 
duration.  
 
 

 
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MATERIALS AND METHODS 
DESIGN. We will conduct a non-randomized controlled intervention study in two comparable Danish 
Regions. Both regions include a university hospital and three regional hospitals and each region 
serves approximately 1.200.000 inhabitants. We aim to include all HPs handling acute patients from 
the pediatric departments in both regions (approx. 600 employees in each region).  
 
INTERVENTION. Participants in the intervention Region will from April 1st, 2023 to April 1st, 2024, 
be exposed to a high-frequency training program, in which each HP will attend four SBTT sessions 
in one year, approx. three months apart. Three-month intervals were chosen based on knowledge of 
retention of technical skills [17][18]. Sessions are estimated to last 30 to 120 minutes. A local 
investigator in each pediatric department will be responsible for planning the SBTT sessions. The 
sessions consist of cases from the abovementioned “scenario bank” including debriefing and will be 
facilitated by a local certified simulation facilitator. 
Pediatric departments in the control Region will conduct SBTT “as usual” with no implemented 
simulation program and with a 2.5 times lower frequency (based on unpublished data). The simulation 
activity in both groups will be meticulously registered in a secure electronic database. Each HP has 
an individual “log” that is registered immediately after each training by a local investigator. 
Registration began on January 1st, 2023, and terminated on March 31st, 2024. 
The intervention is supported by four preliminary initiatives: 
1) 15 extra pediatric simulation facilitators were educated, bringing the total number up to 40.  
2) A two-day pre-intervention workshop for all pediatric simulation facilitators.  
3) A “scenario bank” containing standardized scenarios on common pediatric and neonatal 
emergencies was created and made accessible for simulation facilitators to support 
consistency in the intervention.  
4) Purchase of equipment. Eight Leardal manikins. Four SimPads. Four monitors. During the 
intervention year, these will rotate between the pediatric departments. 
 
DATA COLLECTION. To get the most realistic clinical performance assessment, we will conduct 
unannounced in-situ simulations of pIHCA before and after the intervention in all hospitals. These 
simulations will be video-recorded and are distinctly different from the high-frequency training 
program described in the intervention. The dates of the simulations are unknown to everyone except 
the head nurse who will assign a patient room for the simulation and the researchers enter the room 
unseen. An advanced manikin (Laerdal Little Baby Q-CPR) is placed in a hospital bed. A nurse is 
called to the room and presented with a case story whereafter the simulation session begins. Before 

 
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the study period, all staff members received information informing them to act exactly as they would 
in a real emergency with a true patient (call routines, equipment, medicine, etc.). Four GoPro 
cameras are placed for recording audio and footage to enable assessment. Two assessors will 
independently evaluate each video in a random order (blinded to pre/post and intervention/control) 
to score and extract data. At least one assessor of each video recording will be recruited from outside 
the participating regions to ensure blinding related to recognizability. Discrepancy between 
observers will be settled by discussion and by including a third rater if needed. 
 
Figure 1. Overview of study design. 
 
A total of 122 unannounced simulations will be conducted for performance assessment. Pre-
intervention simulations count 32 in the intervention region and 10 in the control region (a lower 
number to avoid training and Hawthorne effects)[20]. Post-intervention simulations are expected to 
be 40 in each region.  
 
PRIMARY OUTCOMES. 
1) Teamwork competencies. Global team score, assessed with “Team Emergency Assessment 
Measure” measuring leadership control, communication, cooperation, coordination, team 
climate, adaptability, situation awareness, prioritization, and clinical standards 
[21][22][23][24].  
2) Time (seconds) until cardiac arrest is recognized. 

 
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3) Time (seconds) to initiation of cardiopulmonary resuscitation within standard guidelines for 
neonates/children. 
4) Longest chest compression pause duration. 
 
SECONDARY OUTCOMES. 
1) Time (seconds) to: call for help, arrival of defibrillator and first rhythm check. 
2) Proportion of compressions and ventilations within recommendations for depth/rate and 
tidal volumes, respectively.  
 
STATISTICS. Parametric data will be reported as mean (± standard deviation (SD)) and non-
parametric data as median (1st quartile; 3rd quartile). Data will be analyzed using appropriate 
parametric and non-parametric tests. A two-sided p-value < 0.05 will be considered statistically 
significant. We will fit Linear regression models to adjust for important covariates. Primary analyses 
will compare pre- and post-intervention data between intervention and control regions. Secondary 
analyses will compare post-intervention outcome measures for each sub-study by the team members´ 
training exposure in the preceding year regardless of intervention/control status; including the 
number, timing, and topic of training sessions. 
Sample size considerations: For sub-study 1, a total of 62 recordings would be needed to show an 
improvement in the overall TEAM score of 5 points with a power of 80% and a standard deviation 
of 7 points. For sub-study 2, a total of 62 recordings would be needed to show an improvement in 
time to detection of cardiac arrest of 10 seconds with a power of 80% and a standard deviation of 14. 
For sub-study 3, a total of 64 recordings would be needed to show an improvement of 30% in the 
longest chest compression pause duration with a power of 80%. 
 
RESEARCH PLAN AND FEASIBILITY 
The preliminary initiatives and the intervention have been completed as part of a related project 
(Fellow PhD, Anders L. Schram). Future PhD student, Nadja Lindberg Bonne, has successfully 
conducted the collection of the pre-intervention video recordings and is currently conducting the post-
intervention video recordings, which are proceeding according to plan with an expected total of 120 
videos of SBTT from both regions. The project group has the necessary clinical network and academic 
competencies to analyze these highly interesting data with expectations of at least three academic 
articles and presentation of these at both national and international conferences. The feasibility of this 
Ph.D. project is unarguably good, and it will add novel and invaluable clinical data to an existing data 
collection. 

 
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ETHICS 
The studies comply with the recommendations from the Danish Central Ethics Committee. All 
participants will give their written consent. Data will be handled according to The Danish Data 
Protection Agency and the European Union Act on protecting personal data. The project has been 
reported to the internal registry of research projects, the Central Denmark Region, and the Danish 
National Committee on Research Ethics. 
 
PERSPECTIVES 
By providing important knowledge on optimizing and implementing large-scale high-frequency 
training strategies, this project is expected to improve the quality of treatment of pIHCA, with an 
anticipated improvement in mortality and morbidity among survivors. We believe psychological 
safety among HPs will increase, hopefully with decreased sick leave and employee turnover as a 
positive side effect. We expect the results to influence the planning and implementation of future 
onboarding and refresher training programs to ensure high value-for-money approaches in a 
challenged healthcare system. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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