Emergency Department Children Are Not as Sick as Adults: Implications for Critical Care Skills Retention in an Exclusively Pediatric Emergency Medicine Practice

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

INTRODUCTION

Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation.

MATERIALS AND METHODS

We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size.

RESULTS

A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism.

CONCLUSIONS

There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

BACKGROUND

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied.

OBJECTIVES

This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians.

STUDY DESIGN

Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment.

RESULTS

A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure.

CONCLUSIONS

Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians

BACKGROUND

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.

METHODS

Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.

RESULTS

Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.

CONCLUSIONS

Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

Developing a Profile of Procedural Expertise: A Simulation Study of Tracheal Intubation Using 3-Dimensional Motion Capture

BACKGROUND

Improving the assessment and training of tracheal intubation is hindered by the lack of a sufficiently validated profile of expertise. Although several studies have examined biomechanics of tracheal intubation, there are significant gaps in the literature. We used 3-dimensional motion capture to study pediatric providers performing simulated tracheal intubation to identify candidate kinematic variables for inclusion in an expert movement profile.

METHODS

Pediatric anesthesiologists (experienced) and pediatric residents (novices) were recruited from a pediatric institution to perform tracheal intubation on airway mannequins in a motion capture laboratory. Subjects performed 21 trials of tracheal intubation, 3 each of 7 combinations of laryngoscopic visualization (direct or indirect), blade type (straight or curved), and mannequin size (adult or pediatric). We used repeated measures analysis of variance to determine whether various kinematic variables (3-trial average for each participant) were associated with experience.

RESULTS

Eleven experienced and 15 novice providers performed 567 successful tracheal intubation attempts (9 attempts unsuccessful). For laryngoscopy, experienced providers exhibited shorter path length (total distance traveled by laryngoscope handle; 77.6 ± 26.0 cm versus 113.9 ± 53.7 cm; P = 0.013) and greater angular variability at the left wrist (7.4 degrees versus 5.5 degrees, P = 0.013) and the left elbow (10.1 degrees versus 7.6 degrees, P = 0.03). For intubation, experienced providers exhibited shorter path length of the right hand (mean = 61.1 cm versus 99.9 cm, P < 0.001), lower maximum acceleration of the right hand (0.19 versus 0.14 m/s, P = 0.033), and smaller angular, variability at the right elbow (9.7 degrees versus 7.9 degrees, P = 0.03).

CONCLUSIONS

Our study and the available literature suggest specific kinematic variables for inclusion in an expert profile for tracheal intubation. Future studies should include a larger sample of practitioners, actual patients, and measures of the cognitive and affective components of expertise.

Creation of a standardized pediatric emergency medicine simulation curriculum for emergency medicine residents

BACKGROUND

The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills.

METHODS

All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation.

RESULTS

Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation.

CONCLUSIONS

Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department

ABSTRACT

Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission. Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018-2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital. Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%). Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study

BACKGROUND

Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described.

OBJECTIVES

Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children.

METHODS

A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations.

RESULTS

1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures.

CONCLUSION

BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Differences in Utilisation of the General and Paediatric Emergency Departments by Paediatric Patients

INTRODUCTION

Paediatric patients presenting to the general emergency departments (EDs) differ from those presenting to paediatric EDs. General EDs vary in preparedness to manage paediatric patients, which may affect delivery of emergency care with varying clinical outcomes. We aimed to elucidate the differences in utilisation patterns of paediatric and general EDs by paediatric patients.

METHODS

This study was conducted in a public healthcare cluster in Singapore consisting of 4 hospitals. A retrospective review of the medical records of paediatric patients, defined as age younger than 16 years old, who attended the EDs from 1 January 2015 to 31 December 2018, was performed. Data were collected using a standardised form and analysed.

RESULTS

Of the 704,582 attendances, 686,546 (97.4%) were seen at the paediatric ED. General EDs saw greater number of paediatric patients in the emergent (P1) category (921 [5.1%] versus 14,829 [2.2%]; P<0.01) and those with trauma-related presentations (6,669 [37.0%] vs 108,822 [15.9%]; P<0.01). The mortality of paediatric patients was low overall but significantly higher in general EDs (39 [0.2%] vs 32 [0.005%]; P<0.01). Seizure, asthma/bronchitis/bronchiolitis, allergic reaction, cardiac arrest and burns were the top 5 diagnoses that accounted for 517 (56.1%) of all emergent (P1) cases seen at general EDs.

CONCLUSION

General EDs need to build their capabilities and enhance their preparedness according to the paediatric population they serve so that optimal paediatric emergency care can be delivered, especially for critically ill patients who are most in need of life-saving and timely treatment.

Can Providers Use Clinical Skills to Assess the Adequacy of Ventilation in Children During Bag-Valve Mask Ventilation?

OBJECTIVE

Bag-valve mask (BVM) ventilation requires both manual skill and clinical assessment of minute ventilation. Subjective factors can make supplying appropriate ventilation difficult. Capnography is not routinely used when ventilating nonintubated patients. Our objective was to determine if providers were able to maintain normal capnography values with BVM ventilation in pediatric patients based on clinical skills alone.

METHODS

Providers (nurses, residents, and fellows) delivered 2 minutes of BVM respiratory support to healthy children during induction of anesthesia for elective surgery. All patients had standard monitoring including capnography, but providers were blinded to capnography data. Capnography data were video recorded; values between 30 and 50 mmHg were considered indicative of normal ventilation. Any deviation from this range for greater than 10 consecutive seconds was considered an episode of inappropriate ventilation.

MAIN RESULTS

Twenty-five providers-patient pairs were enrolled. Nineteen providers were anesthesia residents. The median age of patients was 5.3 years (interquartile range, 3.3-8.5 years). Nineteen providers (76%) had at least 1 episode of abnormal ventilation with a median of 2 episodes per provider (interquartile range, 0.5-2.5). Among these providers, total mean duration of abnormal ventilation was 57 seconds (95% confidence interval, 41-72) or 47% (95% confidence interval, 34%-60%) of the 2-minute period.

CONCLUSIONS

Normal ventilation is difficult to maintain among providers delivering BVM ventilation to pediatric patients without objective feedback. Incorporation of capnography monitoring may improve BVM ventilation in children.

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs

OBJECTIVES

Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs.

METHODS

Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items.

RESULTS

A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs.

CONCLUSIONS

The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

Critical procedure performance in pediatric patients: Results from a national emergency medicine group

STUDY OBJECTIVE

We sought to examine the frequency of pediatric critical procedures performed in a national group of emergency physicians.

METHODS

We performed a retrospective analysis of an administrative billing and coding dataset for procedural performance documentation verification from 2014 to 2018. We describe and compare incident rates of pediatric (age <18 years) patient critical procedure performance by emergency physicians in general emergency departments (EDs), pediatric EDs, and freestanding ED/urgent care centers. Critical procedures were endotracheal intubation, electrical cardioversion, central venous placement, intraosseous access, and chest tube insertion.

RESULTS

Among 2290 emergency physicians working in 186 EDs (1844 working in 129 general EDs, 125 in 8 pediatric EDs, and 321 in 49 freestanding EDs/urgent cares), a total of 2233 pediatric critical procedures were performed during the study period. Many physicians at general EDs and freestanding EDs/urgent cares performed zero pediatric procedures per year (53.9% and 89% respectively). Per 1000 ED visits seen (All patient ages), physicians working in general EDs performed fewer pediatric critical procedures than physicians in pediatric EDs (0.12/1000 visits vs 0.68/1000 visits; rate difference = 0.56, 95% confidence interval [CI] 0.51-0.61). Per 1000 clinical hours worked, physicians working in general EDs performed 0.26 procedures compared to 1.66 for physicians in pediatric EDs (rate difference = 1.39; 95% CI 1.27-1.52).

CONCLUSION

Pediatric critical procedures are rarely performed by emergency physicians and are exceedingly rare in general EDs and freestanding EDs/urgent cares. The rarity of performance of these skills has implications for ED pediatric readiness.

Spectrum and frequency of critical procedures performed at a Level I adult and pediatric trauma center

OBJECTIVES

The primary objective of this study was to provide physician-level data about the frequency of critical procedures at a combined adult and pediatric Level I trauma center, high-acuity, high-volume academic ED. The inspiration for this study question came from a previous study by Mittiga et al. (2013) describing pediatric critical procedure data at a similar high-acuity, high-volume, pediatric-only academic ED. Our secondary objective is to compare our pediatric level procedural spectrum and frequency with those published by Mittiga et al. (2013).

METHODS

This prospective observational study occurred over eleven consecutive months at an urban, Level I combined adult/pediatric trauma center with 96,000 annual visits (8500 pediatric). We recorded only procedures performed in the resuscitation bays. All data analysis is descriptive.

RESULTS

Over eleven months, data on 3891 resuscitations were collected (3686 adults and 205 children); 38 faculty physicians supervised 1838 total critical procedures, 64 on children. The mean number of critical procedures per physician per month was 4.42 (0.15 on children). Additionally, ultrasound for intravenous access, extended focused assessment with sonography for trauma (e-FAST), or cardiac ultrasound were performed in 3862 resuscitations (178 pediatric).

CONCLUSIONS

Emergency medicine faculty physicians at a combined Level I adult and pediatric trauma center performed and/or supervised 4.4 total (0.15 pediatric) critical procedures per month per faculty which is nearly 6 times more critical procedures monthly than faculty at a similar volume pediatric-only trauma center. However, fewer critical procedures were performed on children at the combined facility.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine

OBJECTIVE

The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation.

METHODS

A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills.

RESULTS

Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children's hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%).

CONCLUSIONS

Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Advances in Emergent Airway Management in Pediatrics

Airway management is the cornerstone to resuscitation efforts for many critically ill pediatric patients presenting for emergency care. Pediatric endotracheal intubation is uncommon in emergency medicine, making it challenging to maintain comfort with this critical procedure. This article offers strategies to facilitate pediatric airway management by addressing predictable anatomic and physiologic differences in children. Also reviewed are alternative approaches to airway management (eg, noninvasive ventilation and videolaryngoscopy) that might be used in cases of recognized difficult airways. Finally, recommendations for maintaining procedural skills in providers who may have limited clinical exposure to critically ill children requiring airway interventions are provided.

In Situ Simulation to Mitigate Threats to Participation in a Multicenter Clinical Trial in High-Acuity, Low-Frequency Setting

INTRODUCTION

Multicenter clinical trials of high-acuity, low-frequency emergencies are expensive and resource intensive. Current standards for trial preparation have significant limitations. Our objective is to describe our use of in situ simulation (ISS) to identify and mitigate threats to enrollment, protocol adherence, and patient safety in preparation for a multicenter clinical trial of antiepileptics for status epilepticus in the emergency department.

METHODS

This is a descriptive study of ISS conducted in the emergency department at a free-standing, academic pediatric institution. We designed two scenarios, one for an eligible and ineligible patient, to allow care teams to complete all study procedures. All study training was completed before the first ISS. Participants included physicians, nurses, patient care assistants, paramedics, research coordinators, and pharmacists. Ten-minute simulations were followed by 10-minute debriefings, led by trained facilitators using a standard template. Data on threats to enrollment, protocol adherence, and patient safety were recorded. Mitigation strategies were developed by the study team and local experts in ISS.

RESULTS

Ten of 18 planned simulations were conducted. Seven of 10 completed simulations were study eligible patients, with 73 total participants. Nine threats to enrollment and five to protocol adherence were identified. Five of 14 were also threats to patient safety. Mitigation strategies included creation of decision aid tools, targeted education during debriefings, adapting study material for use, and revision of status epilepticus treatment algorithm.

CONCLUSIONS

The addition of ISS to standard preparation for a multicenter clinical trial facilitated the identification and mitigation of threats to study participation and patient safety.

Preferred learning modalities and practice for critical skills: a global survey of paediatric emergency medicine clinicians

Objective

To describe senior paediatric emergency clinician perspectives on the optimal frequency of and preferred modalities for practising critical paediatric procedures.

Methods

Multicentre multicountry cross-sectional survey of senior paediatric emergency clinicians working in 96 EDs affiliated with the Pediatric Emergency Research Network.

Results

1332/2446 (54%) clinicians provided information on suggested frequency of practice and preferred learning modalities for 18 critical procedures. Yearly practice was recommended for six procedures (bag valve mask ventilation, cardiopulmonary resuscitation (CPR), endotracheal intubation, laryngeal mask airway insertion, defibrillation/direct current (DC) cardioversion and intraosseous needle insertion) by at least 80% of respondents. 16 procedures were recommended for yearly practice by at least 50% of respondents. Two procedures (venous cutdown and ED thoracotomy) had yearly practice recommended by <40% of respondents. Simulation was the preferred learning modality for CPR, bag valve mask ventilation, DC cardioversion and transcutaneous pacing. Practice in alternative clinical settings (eg, the operating room) was the preferred learning modality for endotracheal intubation and laryngeal mask insertion. Use of models/mannequins for isolated procedural training was the preferred learning modality for all other invasive procedures. Free-text responses suggested the utility of cadaver labs and animal labs for more invasive procedures (thoracotomy, intercostal catheter insertion, open surgical airways, venous cutdown and pericardiocentesis).

Conclusions

Paediatric ED clinicians suggest that most paediatric critical procedures should be practised at least annually. The preferred learning modality depends on the skill practised; alternative clinical settings are thought to be most useful for standard airway manoeuvres, while simulation-based experiential learning is applicable for most other procedures.

Simulation-based training for trauma resuscitation among ACS TQIP-Pediatric centers: Understanding prevalence of use, associated center characteristics, training factors, and implementation barriers

BACKGROUND

Simulation-based training (SBT) for pediatric trauma resuscitation can improve team performance. The purpose of this study was to describe the nationwide trend in SBT use and barriers to SBT implementation.

METHODS

Trauma centers that participated in ACS TQIP Pediatric in 2016 (N = 125) were surveyed about SBT use. Center characteristics and reported implementation barriers were compared between centers using and not using SBT.

RESULTS

Survey response rate was 75% (94/125) with 78% (73/94) reporting SBT use. The frequency of pediatric SBT use increased from 2014 to 2016 (median 5.5 vs 6.5 annual sessions, p < 0.01). Funding barriers were negatively associated with number of annual SBT sessions (r ≤ -0.34, p < 0.05). Centers not using SBT reported lack of technical expertise (p = 0.01) and lack of data supporting SBT (p = 0.03) as significant barriers.

CONCLUSIONS

Simulation use increased from 2014 to 2016, but significant barriers to implementation exist. Strategies to share resources and decrease costs may improve usage.

LEVEL OF EVIDENCE

Level 3, epidemiological.

Epidemiology of the Critically Ill Child in the Resuscitation Bay

BACKGROUND

Children account for approximately 33 million annual emergency department (ED) visits in the United States. The spectrum and frequency of children with a critical illness presenting to an ED has not been previously analyzed.

OBJECTIVE

The purpose of this study was to examine the range of critical illness presenting to a tertiary Children's Hospital ED.

METHODS

This study was a retrospective chart review of all pediatric patients requiring immediate care in the medical resuscitation bay during a 25-month period from August 2005 to September 2007. Data are from a single center, academic, tertiary care pediatric hospital. A log of all patients requiring immediate care is kept in the medical resuscitation bay. Patients recorded in the log for a period of 25 consecutive months were reviewed for type of critical illness, frequency of critical illness, mode of arrival, and outcome. Trauma patients were excluded.

RESULTS

There were approximately 45,000 pediatric visits per year with a total of 87,766 patients seen during the study period. There were 249 pediatric patients who required care in the medical resuscitation bay during the reviewed period. Complete data were obtained from 242 subjects' charts. Patients requiring immediate care accounted for 0.28% of all the visits.

CONCLUSIONS

This study documents the infrequent need for pediatric critical care in the ED of a nonacademic tertiary children's hospital in the United States and reinforces the need to provide protocols, mock codes, and simulation labs in preparation for critically ill children.

Essentials of Pediatric Emergency Medicine Fellowship: Part 3: Clinical Education and Experience

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

An Analysis of Intravenous Catheter Placement Among Patients in a Pediatric Emergency Department

OBJECTIVES

Pediatric emergency departments (PED) are overcrowded and at times inefficient with malaligned resources, especially regarding the use of intravenous (IV) catheters which are placed frequently, yet may be underused. This study seeks to determine which pediatric patients are more likely to need IV access in a PED.

METHODS

This retrospective study examined patients 3 days to 21 years seen in a tertiary PED from January 1, 2013, to February 28, 2013, who were triaged using the Emergency Severity Index, levels 1 to 3. Extracted data included age, chief complaints, chronic medical conditions, final diagnoses, evidence of venipuncture, and IV placement and usage. Patients were excluded if they entered the PED with an IV or central venous catheter, were older than 21 years, or had charts with missing data.

RESULTS

Four thousand three hundred twenty-two patients were initially evaluated, and 122 patients were excluded. Mean age of the patients was 6.2 years (SD = 5.65), most common triage was level 3 (urgent), and the majority of patients (n = 2898, 69.0%) did not have a chronic medical condition. Five hundred forty-five (13%) had IVs placed, and of those, 152 (27.9%) had IVs placed and not used. Patients triaged as critical or emergent, patients older than 10 years, and those with a gastrointestinal chief complaint and chronic medical conditions involving hematology, oncology/immunology, or endocrinology were most likely to have an IV placed and used.

CONCLUSIONS

Patients with higher acuities, specified systemic complaints, certain chronic medical conditions, and patients older than 10 years are more likely to need an IV.

Pediatric Out-of-Hospital Critical Procedures in the United States

OBJECTIVE

Regular clinical application is important for maintenance of difficult resuscitation skills. Although emergency medical services must provide life-saving care for critically ill and injured children, the frequency with which these procedures are performed is unknown. We sought to characterize critical pediatric procedures performed by emergency medical service personnel in the United States.

DESIGN

We performed a retrospective, descriptive study of emergency medical service responses.

SETTING AND PATIENTS

We included patients less than 18 years old in the 2011 National Emergency Medical Services Information Systems national data set. We identified emergency medical service cases receiving critical procedures, including intubation, cricothyroidotomy, cardiac pacing, cardioversion, defibrillation, needle decompression, pericardiocentesis, and intraosseous or central venous catheter placement.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed the data to determine the number and prevalence of procedures, success rates, and factors associated with success. Of the 14,371,941 emergency medical service responses, 865,591 (6.8%) involved children. Emergency medical service responses to pediatric patients most often involved traumatic injuries (35.7%) or respiratory complications (13.2%). Emergency medical service performed a total of 616,913 procedures on 246,016 pediatric cases. Critical procedures were infrequently performed (n = 11,026, 10 per 1,000 pediatric cases). The most common critical procedures performed were intubation (n = 3,599, 6.7 per 1,000 pediatric cases) and intraosseous access (n = 2,618, 5 per 1,000 pediatric cases). Overall, 81% of critical procedures were successful. Increasing age and interfacility transfers were associated with greater odds of procedural success (p < 0.01).

CONCLUSION

Despite the broad range of pediatric conditions seen in the prehospital setting, pediatric critical procedures are infrequently performed. These data highlight factors that are associated with successful completion of critical pediatric procedures.

Improving process quality for pediatric emergency department

PURPOSE

Overcrowding in emergency departments (EDs) leads to longer waiting times and results in higher number of patients leaving the ED without being seen by a physician. EDs need to improve quality for patients' waiting time and length of stay (LoS) from the perspective of process and flow control management. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The retrospective case study was performed using the computerized ED patient time logs from arrival to discharge between July 1, 2009 and June 30, 2010. Patients were divided into two groups either adult or pediatric with a cutoff age of 18. Patients' characteristics were measured by arrival time periods, waiting times before being seen by a physician, total LoS and acuity levels. A discrete event simulation was applied to the comparison of quality performance measures.

FINDINGS

Statistically significant differences were found between the two groups in terms of arrival times, acuity levels, waiting time stratified for various arrival times and acuity levels. The process quality for pediatric patients could be improved by redesign of patient flow management and medical resource.

RESEARCH LIMITATIONS/IMPLICATIONS

The results are limited to a case of one community and ED. This study did not analyze the characteristic of leaving the ED without being seen by a physician.

PRACTICAL IMPLICATIONS

Separation of pediatric patients from adult patients in an ED can reduce the waiting time before being seen by a physician and the total staying time in the ED for pediatric patients. It can also lessen the chances for pediatric patients to leave the ED without being seen by a physician.

ORIGINALITY/VALUE

A process and flow control management scheme based on patient group characteristics may improve service quality and lead to a better patient satisfaction in ED.

Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review

STUDY OBJECTIVE

Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).

METHODS

We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.

RESULTS

We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.

CONCLUSION

Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.