Pediatric Fundamental Critical Care Support "Free Download"
J Int Med Res. 2018 November; 46(11): 4640–4649.
Functioning comparison in Pediatric Fundamental Critical Care Support among staff from the USA versus those from resources-limited countries
Received 2017 Nov 3; Accustomed 2018 Jun fifteen.
Short abstruse
Objective
This study aimed to evaluate the performance of participants in the United states compared with international participants taking the Pediatric Fundamental Critical Care Back up (PFCCS) course, and the significance of preparation for resource-limited environments.
Methods
PFCCS courses were conducted in the Usa, El Salvador, Republic of haiti, Kenya, and Nepal betwixt Jan 2011 and July 2013. All of the participants took pre- and post-tests. We compared the performance of these tests betwixt international and USA participants. All participants answered a post-course survey to evaluate the didactic lectures and skill stations.
Results
A total of 244 participants took the PFCCS form, comprising 71 from the USA, 68 from Kenya, 37 from Haiti, 48 from Nepal, and 20 from El salvador. The mean pre-exam score of The states participants (l.6%) was significantly higher than that of international participants (44.vii%). There was no significant departure in the post-test score between United states and international participants (78.6% versus 81.4%). In that location was a pregnant difference between pre- and post-test scores. At that place was amend appreciation of the grade content by the Usa participants.
Conclusion
International grade takers without prior pediatric intensive care training have like test scores to Us participants suggesting comparable efficacy.
Keywords: Intensive care, Pediatric Fundamental Critical Intendance Support (PFCCS), resource-limited environment, chapters building, global health, medical staff training
Introduction
Pediatric Cardinal Critical Care Support (PFCCS) is a 2-day course that was developed by the Society of Critical Care Medicine (SCCM) to come across the needs of pediatric critical care children in the absence of a pediatric intensivist. This grooming prepares healthcare personnel with limited pediatric critical intendance experience with the fundamentals to stabilize critically ill children during the starting time 24 to 48 hours.1,2 PFCCS was inspired by the Fundamental Critical Intendance Support class, which has provided training for adult critical care globally since the mid-1990s.
Dissimilar Pediatric Advanced Life Back up (PALS), the PFCCS grade attempts to address acute management, resuscitation, stabilization, and ongoing care of critically sick pediatric patients. PALS is supported past the American Heart Association. PALS is a class that is mainly designed to address acute resuscitation of pediatric patients for healthcare providers.three The SCCM released the first edition of the PFCCS class textbook in May 2008. The PFCCS course apace gained acceptance as a standardized method of disseminating the fundamental concept of pediatric critical care services. This course was designed for healthcare providers who are involved in initial direction and/or transfer of critically ill or injured infants and children in the USA, in developing countries, and in resource-limited areas.4
In September 2010, a group of pediatric intensivists and nurses, committed to the evolution of pediatric critical care services prepare out to teach this form in 4 resource-limited countries where there was no formal pediatric disquisitional care grooming for health care providers, through a non-turn a profit arrangement Pediatric Universal Life-Saving Effort (PULSE). Since so, PULSE focuses on edifice a global health network, as well as improving healthcare commitment to critically ill patients in countries with limited resources. PULSE's global health teams are led by doctors who have an intimate knowledge of the local infrastructure and medical teaching system. The team members include PFCCS consultants and instructors and volunteers from the United states with a commitment to development of pediatric critical care service in their native countries. We conducted the kickoff PFCCS class on the African continent in Nairobi, Kenya in March 2011. This grade served to railroad train medical personnel who currently work within acute intendance areas inside pediatric wards, accident and emergency, pediatric intensive care units equally well as general intensive care units within Kenya, where critically sick pediatric patients are admitted. Later, PULSE volunteers conducted several courses in Nepal, Haiti and El salvador.
This written report aimed to investigate the relevance and efficacy of the PFCCS grade in resources limited countries in augmenting pediatric critical care services. We compared the performance of international participants with those from the Usa to decide if the PFCCS course needs to be modified for limited-resources environments.
Materials and methods
Intervention
The PFCCS course is a ii-day educational program with didactic lectures and skill stations. The educational fabric for each twenty-four hours encompasses an 8-60 minutes session that balances a nearly equivalent amount of time spent between didactic lectures and practical sessions.two The didactic lectures include core topics in pediatric disquisitional intendance, such as astute respiratory failure, mechanical ventilation, stupor, astute infection, fluid and electrolyte direction, neurologic emergencies, trauma and send of the critically ill child. This course also includes skill stations in airway evaluation and management, mechanical ventilation, sedation, trauma, transport, invasive devices and their potential complications. A standard textbook published by the SCCM is as well role of the educational material. The target audience of PFCCS includes hospitalists, avant-garde practise nurses, dr. administration, rapid response teams, disquisitional care fellows, nursing staff, and other pre-infirmary providers involved in the intendance of unstable, critically ill, or injured pediatric patients. The grade content is divided into chapters that reflect current guidelines and practices regarding central aspects of pediatric disquisitional care. At that place is an emphasis on preparing participants for management of acutely deteriorating pediatric patients, within the offset 24 hours postal service-resuscitation until appropriate transfer or consultation with a pediatric intensivist tin can be bundled. The PFCCS class is designed to promote teamwork while teaching the fundamentals of critical intendance and does non intend to substitute the pediatric intensivist. A pre-requisite for the course candidate includes certification in basic life back up and PALS.v–7 The skill stations are designed to allow the candidates to perform as equal members, while performing different roles, including squad leadership.
In 2009, the pediatric intensive care unit (PICU) staff in our institution decided to better the competency of PICU nurses, hospitalists, emergency physicians, and pediatric residents. We identified the PFCCS as a strategic tool for implementing this projection. The New York Pediatric Disaster Coalition to which our hospital belongs too recommends the PFCCS every bit a training tool for not-critical intendance medical staff.8,9 The courses were taught by strict adherence to the protocol and standard specified by the SCCM.
Later on, the same group of pediatric intensivists conducted the global health projection to develop pediatric intensive care in resource-limited settings. PULSE began this project in Republic of haiti, Kenya, Nepal and El Salvador with the goal of stimulating starting points for creating pediatric intensive intendance hubs and preparation centers. From March 2011 to August 2013 five PFCCS courses were conducted at The Brooklyn Hospital Center. The attendees of this course in the Usa included pediatric nurses, nurse practitioners, pediatric residents, and pediatric hospitalists from the PICUs and pediatric emergency departments of community hospitals. We recruited candidates for the United states of america courses by direct promotion via our hospital website. Additionally, the SCCM website published the course dates on the approved PFCCS website. These courses included attendees from vii different U.s.a. hospitals with level Two PICUs in accord with the following guidelines.10 In 1993, the Pediatric Section of the Society of Critical Care Medicine and the Section on Critical Care Medicine and Committee on Infirmary Care of the American Academy of Pediatrics issued guidelines for the level of intendance in PICUs in the United States. The guidelines land that "pediatric critical care is ideally provided past a PICU that meets level I specifications".10 Level I PICUs have the resources to care for a wide range of complex medical and surgical critical illnesses for pediatric patients of all ages, including newborns and premature infants. Level Two PICUs have fewer resources with less availability of pediatric intensivists and other subspecialty services compared with level I PICUs.
Study design
A retrospective assay of several courses that were conducted internationally and in the United states of america was performed. We compared test performances for theoretical knowledge and mail service-course evaluation by the participants for a descriptive assay of the class delivery. Eight courses were conducted internationally at institutions without PICUs, comprising three in Kenya, two in Haiti, ii in Nepal, and 1 in El Salvador. None of the form participants had formal pediatric disquisitional care training. The goal of providing these courses in countries with express resources was to eternalize disquisitional care services, improve healthcare delivery, and lessen the healthcare disparity that exists in resource-limited areas. The international participants consisted of pediatric and developed nurses, advanced practise nurses, attending physicians, hospitalists, and pediatric residents. None of these participants had prior exposure to pediatric critical care.
The participants for the international courses were selected to participate in the form based on the staffing needs of the hospitals that were interested in developing PICU hubs in association with PULSE. These participants included staff physicians who were likely to intendance for patients in the emergency room and pediatric special care units.
Certified PFCCS instructors who were led past a course director in conjunction with a grade consultant conducted the courses later on obtaining a license from SCCM. The course consultants were the same for all of the courses. The directors were also present during all of the courses, and rotated as directors and instructors as part of the same team. The class consultants and directors had all-encompassing experience and maintained their status by SCCM standards by education at least two courses per year. The preparation program strictly adhered to the standards set by the SCCM without any deviation. The participants received PFCCS textbooks several weeks before the grade appointment with emphasis on a listing of core chapters. At the beginning of the 2-mean solar day form, each participant The international participants consisted of nurses, general practitioners and hospitalists, pediatric residents, pediatricians and diverse pediatric sub-specialists. None of these providers had prior exposure to formal pediatric critical care training. took a pre-test to appraise their baseline theoretical cognition in pediatric disquisitional care. Each form had an average of 24 participants. Nosotros divided the participants into groups of six to eight with an assigned certified instructor to conduct the skill stations. Each skill station had standardized case scenarios that required a goal-directed arroyo to the patient'south management based on the acronym of DIRECT (Detection, Intervention, Reassessment, Communication, and Teamwork). As part of the course requirement, the class director reviewed the 10 pre-test questions with the participants during the wrap-upwardly session. At completion of the class, we administered 50 multiple pick post-test questions to the candidates. The passing form required a minimum score of 35 (70%) correct answers. The test questions and the passing score were established by a grouping of pediatric critical intendance experts who were office of a committee as an editing chore forcefulness for the PFCCS textbook. The questions were ofttimes reviewed to ensure a level of fundamental pediatric critical care knowledge. The task force stipulated that a raw score of 35 out of 50 (70%) questions was sufficient to institute proficiency of the participants subsequently the 2-twenty-four hours course. The participants completed a standardized anonymous course evaluation survey provided by the SCCM. The survey included demographic data and questions answered on a 5-point Likert calibration that qualified the applicability, satisfaction, and relevance of the class. The Institutional Review Board of The Brooklyn Hospital Middle reviewed the questionnaire for whatsoever risk to subjects and approved the study. The Institutional Review Board of The Brooklyn Hospital Center waived the need for informed consent of the subjects because of the retrospective study design and employ of an anonymous survey.
Assay
We retrospectively reviewed the post-test score, demographics, and survey results for the U.s. and international participants. Values are shown as mean ± standard divergence or numbers and percentages. We indexed the data on a spreadsheet and analyzed the operation of the two groups using the ii-tailed unpaired t-examination with JMP software (SAS Found, Cary, NC, USA).
Results
The distribution of participants by country was 71 (29%) in the USA, 68 (28%) in Kenya, 37 (15%) in Haiti, 48 (20%) in Nepal, and 20 (8%) in Republic of el salvador (Effigy ane). The theoretical knowledge every bit a result of pre-exam scores was higher in The states participants than in international participants (p = 0.039). Nonetheless, the mail-test scores were similar between U.s.a. and international participants. We trained a total of 244 healthcare professionals. Of these, 123 (50%) were practicing physicians, 55 (23%) were nurses, 44 (18%) were physicians in training, and 22 (9%) were other allied professionals (Figure 2). Of the 173 international participants, 64% were physicians, 18% were pediatric residents, 10% were nurses, and 8% were allied healthcare professionals. A total of 144 (66%) of the participants had one to 5 years of clinical feel, 14 (eight%) had five to 10 years of practice, 37 (21%) had greater than 10 years of practise, and 8 (v%) did not report their years of experience. A total of 50% of participants worked in a academy hospital setting, 31% worked in a community hospital, and nineteen% worked in non-hospital settings. Of the 71 The states participants, 51% were nurses, thirteen% were nurse practitioners, 17% were pediatric residents, and 17% were practicing physicians. A full of 33 (46%) of participants had one to 5 years of clinical experience, nine (xiii%) had 5 to 10 years of practice, 27 (38%) had greater than x years of practice, and four (6%) did not written report their years of experience. A full of 55% of participants worked in a community hospital affiliated with a university center.
Distribution of course participants.
Distribution of participants by profession.
Assay of the pre-test showed a significantly higher mean score for United states participants (50.6% ± 22.05%) compared with international participants (44.7% ± 20.five%, p < 0.05). The U.s.a. median test score was l% and the international median score was 40%. The overall mean score of the postal service-examination for all candidates was 80.8% ± nine.5%. In that location was no significant difference in the hateful mail service-test score of U.s. and international participants (78.half-dozen% versus 81.4%). The mail service-exam score for each of the groups showed a meaning improvement in score compared with the pre-test score (paired t-examination, both p < 0.001 for international and USA).
The mail service-course survey showed a high appreciation for the course content by the USA and international participants. The responses of the participants showed a significant difference between the two groups for assessment of clinical application of the course (U.s., 4.64 ± 0.seventy versus international, 4.36 ± 0.67, p = 0.002). Other questions that evaluated satisfaction of the lectures and skill stations showed a significantly greater appreciation of the course by USA participants than by international participants (all p < 0.001, Tables 1 and 2).
Table i.
Comparison of lecture evaluations.
| Lectures | United states score | International score | p value |
|---|---|---|---|
| Respiratory failure | 4.80 ± 0.58 | 4.46 ± 0.44 | <0.0001 |
| Pediatric shock | 4.77 ± 0.45 | 4.56 ± 0.53 | <0.0001 |
| Neurological emergencies | four.68 ± 0.61 | 4.37 ± 0.63 | <0.0003 |
| Trauma | 4.67 ± 0.65 | iv.24 ± 0.77 | <0.0001 |
| Fluids and electrolytes | four.seventy ± 0.58 | 4.29 ± 0.70 | <0.0001 |
| Ship | iv.lxx ± 0.58 | 4.29 ± 0.70 | <0.0001 |
| Postoperative care | 4.71 ± 0.53 | four.21 ± 0.66 | <0.0001 |
| Sedation | iv.68 ± 0.58 | 4.39 ± 0.62 | <0.0003 |
Tabular array two.
Comparison of skill station evaluations.
| Skill stations | U.s. score | International score | p value |
|---|---|---|---|
| Airway management | iv.73 ± 0.84 | iv.34 ± 0.55 | <0.0001 |
| Pediatric stupor | 4.73 ± 0.48 | 4.23 ± 0.68 | <0.0001 |
| Mechanical ventilation I | 4.71 ± 0.65 | 4.37 ± 0.52 | <0.0001 |
| Mechanical ventilation II | 4.76 ± 0.45 | 4.40 ± 0.63 | <0.0001 |
| Trauma | 4.64 ± 0.59 | iv.35 ± 0.62 | <0.0005 |
Discussion
The PFCCS course serves to increase the theoretical knowledge of pediatric and non-pediatric practitioners in the Usa caring for critically ill pediatric patients. This applies to the intensive care setting, emergency room, ship, lower level PICUs for the first 24 hours until advisable transfer or advanced level of care is available. However, this course may not be every bit applicable in resource-limited countries where pediatric critical intendance infrastructure has not even so been established. Atagi et al.11 suggested that the FCCS and PFCCS could exist used in areas where there is no standardized preparation system for critical care in Nihon. Turner et al.12 made similar observations in sub-Saharan Africa.
To date, few published data have addressed the relevancy of the PFCCS course in improving staff preparedness to care for critically sick pediatric patients. Werner and Bruzzini concluded that the PFCCS grade is efficacious in improving the perception of pediatric residents and nurse practitioners in recognition and direction of critically ill children.thirteen A total of 50% of the participants in our survey were in preparation with limited or no exposure to formal pediatric critical care. Therefore, whether self-efficacy equates to actual readiness to care for sick pediatric patients is unknown.xiv In that location is prove that similar courses implemented in Zambia and Kenya increased noesis, confidence, and added new skills relevant to these resource-limited areas.15,16 Rodenbarger et al.17 reported that PFCCS courses improved self-efficacy, preparedness, and the skills of pediatric physicians in grooming.
PFCCS courses that were conducted nationally and internationally used consultants, directors, and instructors with minimal variability in team composition. We compared the performances of pediatric healthcare practitioners from the U.s. who worked in level II PICUs with those from resource-limited countries with express or no exposure to pediatric critical care. Both groups had similar scores on the post-test. This finding suggests that the cognition in core critical care concepts tin be assimilated by healthcare providers who take little or no exposure to critical care because it is skilful in industrialized countries. While this is indicative of new skills and noesis, successful completion of a PFCCS course may exist a surrogate for improving outcomes.
In our written report, mail service-course evaluation of the lectures showed that there was a small, only significant, difference in satisfaction between USA and international participants. A factor that tin explain this finding is the difference in demographic composition of the participants. The USA participants mostly comprised nurses and nurse practitioners who worked in medium-sized PICUs that were staffed with pediatric intensivists. In contrast, most of the international participants were physicians. The international participants had a lower appreciation score for all of the skill stations and lectures. An explanation for this observation might be related to the lack of familiarity with the equipment displayed at the skill stations. Furthermore, equipment for primal venous line placement and mechanical ventilation are not readily available in most of the areas where international participants exercise.18 Finally, the lack of a standardized protocol for direction of trauma in these countries may account for these observations.19 Considering of the limited resource and the difficulty in transporting loftier-fidelity simulators, we only conducted the skill stations for international participants using a depression-fidelity simulation model. Considering these factors, the perception of the value and relevance of the skill stations reported by the international candidates may take been afflicted.20
The content of the didactic and skill stations of the PFCCS course were primarily designed for healthcare providers in industrialized nations where resources and technology may be readily available. Historically, the FCCS and PFCCS courses were designed for resource-rich countries, and their awarding was not meant to replace the role of the intensivist in managing critically ill patients.21 In contrast, there is a higher burden of disease in resource-poor settings. The potential for incremental benefit may be higher in the goal to decrease morbidity and mortality in resource-limited environments.22 In our study, on the footing of feedback received from the beginning form, we incorporated the application of bubble continuous positive airway pressure level equally role of the ventilator skill station in Haiti as the well-nigh available and depression-price class of respiratory support for newborns and small infants in that country.23,24 We hope to larn more understanding on the role of pediatric disquisitional care in resource-limited environments. Nonetheless, success of any training programme may be dependent on many factors, including the price, resource allocation, healthcare workforce and education, task-shifting,12,18 and the combination with local clinical practices.
There are limitations to the results of our study. The two studied groups were heterogenous because the international participants were mostly physicians, whereas the USA participants had more allied healthcare professionals. Additionally, the operation in theoretical knowledge of participants pre- and post-course could not be determined because the pre-test was a limited version of the mail service-test. Finally, the international group was not exposed to the high-allegiance simulation feel. Still, a formal testing of the skill stations was not part of the course standard, except for the post-form survey evaluation returned past the participants.
The PFCCS class served equally an introduction to the concepts and practice of pediatric critical intendance, especially for international participants. According to our anecdotal experience and the observations of Ralston et al.,25 the providers whom nosotros trained are currently assuming the function of a pediatric intensivist. Furthermore, implementation of this course on a regular basis was a catalyst for local development of critical care services and implementation of disquisitional intendance training programs by others.22,26 Future assessment studies in implementation may show changes in the infrastructure for resource-limited areas. We hope to add howdy-fidelity simulation to our preparation and evaluation process in the near futurity to enhance the course, equally well as clinical outcomes.27
Conclusions
The theoretical functioning of international participants in the PFCCS form is comparable to that of participants from the USA. At that place is a greater appreciation of the skill stations and didactic lectures by USA participants than by international participants. Farther study is warranted to decide the true consequence of cultural differences in survey responses. We speculate that introduction of high-fidelity simulation integrated with the scenarios during our skill stations during the form may heighten the psychomotor abilities of physicians and other practitioners.27–31
Acknowledgement
The authors acknowledge the contribution of Dr. Kenneth Bromberg in reviewing and editing the manuscript.
Annunciation of alien interest
The authors declare that there is no conflict of interest.
Funding
The authors received no fiscal back up for the research, authorship, and/or publication of this article.
References
ane. Medicine S of CC. Pediatric fundamental critical care. 1 ed Mountain Prospect, IL: Society of Critical Care Medicine, 2008, p.392. [Google Scholar]
3. Zaritsky A, Nadkarni 5, Hazinski MF, et al. Recommended guidelines for uniform reporting of pediatric advanced life support: the pediatric Utstein Style. A argument for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council. Writing Grouping. Apportionment 1995; 92: 2006–2020. [PubMed] [Google Scholar]
iv. Tegtmeyer G, Conway EE, Jr, Upperman JS, et al. Education in a pediatric emergency mass disquisitional care setting. Pediatr Crit Intendance Med 2011; 12(6 Suppl): S135–S140. [PubMed] [Google Scholar]
v. de Caen AR, Maconochie IK, Aickin R, et al. Part 6: Pediatric Bones Life Back up and Pediatric Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Handling Recommendations. Circulation 2015; 132(16 Suppl 1): S177–203. [PubMed] [Google Scholar]
6. Kleinman ME, de Caen AR, Chameides Fifty, et al. Part 10: Pediatric basic and avant-garde life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122(16 Suppl ii): S466–S515. [PMC free commodity] [PubMed] [Google Scholar]
vii. Atkins DL, Berger S, Duff JP, et al. Office eleven: Pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132(eighteen Suppl 2): S519–S525. [PubMed] [Google Scholar]
8. Campbell C. The benefits of designing a stratification system for New York City pediatric intensive intendance units for utilize in regional surge capacity planning and management. J Community Wellness 2010; 35: 337–347. [PubMed] [Google Scholar]
9. Frogel M, Flamm A, Sagy M, et al. Utilizing a pediatric disaster coalition model to increase pediatric disquisitional care surge chapters in New York City. Disaster Med Public Wellness Prep 2017; 11: 473–478. [PubMed] [Google Scholar]
10. Rosenberg DI, Moss MM, American University of Pediatrics Section on Critical Care et al. Guidelines and levels of care for pediatric intensive care units. Pediatrics 2004; 114: 1114–1125. [PubMed] [Google Scholar]
13. Werner J, Bruzzini D. 623: PFCCS improves perceived self-efficacy in a variety of providers. Crit Care Med 2012; 40: 1. [Google Scholar]
14. Afonso N, Cox Thou, Kloeck D, et al. 382: Noesis accrual after a pediatric fundamental critical care support course in Botswana. Crit Intendance Med 2016; 44: 172. [Google Scholar]
fifteen. MacLeod JB, Okech One thousand, Labib M, et al. Evaluation of trauma and disquisitional intendance training courses on the cognition and confidence of participants in Kenya and Zambia. World J Surg 2011; 35: 9–16. [PubMed] [Google Scholar]
16. Macleod JB, Jones T, Aphivantrakul P, et al. Evaluation of fundamental critical intendance form in Republic of kenya: cognition, mental attitude, and practice. J Surg Res 2011; 167: 223–230. [PubMed] [Google Scholar]
17. Rodenbarger AL, Maa T, Chase M, et al. Effectiveness of pediatric fundamentals of critical intendance support (PFCCS) in enhancing resident self-efficacy and skills. Acad Pediatr 2016; 16: e54. [Google Scholar]
18. Bhattarai P, Kioko M, Sharma P, et al. 631: Assessment of pediatric disquisitional care in Nepal . Crit Intendance Med 2013; 41: A155. [Google Scholar]
19. Schultz CR, Ford HR, Cassidy LD, et al. Development of a infirmary-based trauma registry in Haiti: an approach for improving injury surveillance in developing and resources-poor settings. J Trauma 2007; 63: 1143–1154. [PubMed] [Google Scholar]
twenty. Munshi F, Lababidi H, Alyousef S. Depression- versus high-fidelity simulations in teaching and assessing clinical skills. J Taibah Univ Med Sci 2015; 10: 12–15. [Google Scholar]
21. Dellinger RP. Fundamental disquisitional care back up: Another merit badge or more? Crit Care Med 1996; 24: 556. [PubMed] [Google Scholar]
22. Basnet S, Shrestha S, Ghimire A, et al. Development of a PICU in Nepal: the experience of the first twelvemonth. Pediatr Crit Care Med 2014; 15: e314–e320. [PubMed] [Google Scholar]
23. Jayashree Yard, KiranBabu HB, Singhi Southward, et al. Utilize of nasal bubble CPAP in children with hypoxemic clinical pneumonia—report from a resource limited fix-up. J Trop Pediatr 2016; 62: 69–74. [PMC costless commodity] [PubMed] [Google Scholar]
25. Ralston ME, Day LT, Slusher TM, et al. Global paediatric advanced life back up: improving child survival in limited-resource settings. Lancet Lond Engl 2013; 381: 256–265. [PubMed] [Google Scholar]
27. High-Fidelity simulation enhances pediatric residents' retention, knowledge, procedural proficiency, grouping resuscitation performance, and experience in pediatric resuscitation | Research Manufactures | Infirmary Pediatrics [Internet]. [cited 2018. May 8]. Bachelor from: http://hosppeds.aappublications.org/content/3/3/266 [PubMed]
29. Akingbola O, Touchard C, Singh D, et al. Practical approach to a simulation based form in pediatric critical care. MedEdPORTAL [Internet]. 2014 May 14 [cited 2018. May eight];(10). Bachelor from: https://world wide web.mededportal.org/publication/9796/
31. Tofil NM, Benner KW, Zinkan L, et al. Pediatric intensive care simulation grade: a new prototype in pedagogy. J Grad Med Educ 2011; 3: 81–87. [PMC free article] [PubMed] [Google Scholar]
DOWNLOAD HERE
Posted by: pearsonbegivest.blogspot.com