Quality Improvement Initiative Using Blended In Situ Simulation Training on Procedural Sedation and Analgesia in a Pediatric Emergency Department: Better Patient Care at Lower Costs

Procedural sedation and analgesia in Swiss Pediatric Emergency Departments: a national subgroup analysis of a European cross-sectional survey

This study aims to provide a national overview of procedural sedation and analgesia practices within Pediatric Emergency Departments in Switzerland, focusing on the availability of pharmacologic agents, the presence of safety protocols, the utilization of non-pharmacological interventions, and to identify specific local limitations. We conducted a detailed subgroup analysis of Swiss data from a European cross-sectional survey on emergency department pediatric Procedural Sedation and Analgesia (PSA) practice, isolating data from Swiss sites. The survey, conducted between November 2019 and March 2020, covered various aspects of procedural sedation and analgesia practices. The survey included nine Swiss sites, treating a total of 252,786 patients in 2019. Topical analgesia, inhaled equimolar nitrous oxide-oxygen mixture, and ketamine were largely available. All sites had nurse-directed triage protocols in place; however, opioid administration was included in the protocols in only 66% of sites. Only 33% of hospitals reported common use of intravenous sedation. Barriers to procedural sedation and analgesia implementation included staffing shortages (89% of sites) and lack of dedicated spaces (78%).Conclusions: Despite a broad array of pharmacological and options available in Swiss Pediatric Emergency Departments, challenges remain in standardizing practices across the country. Limited space and staffing and enhancing training on non-pharmacological interventions were identified as potential areas for improving pain and anxiety management in pediatric emergency care. This study underscores the need for national guidelines to harmonize emergency department PSA practices across Switzerland, ensuring all children have access to effective and evidence-based procedural comfort. What is Known: • Recent research, conducted in European emergency departments, suggests that in pediatric Procedural Sedation and Analgesia (PSA) resources are limited, and practice is heterogeneous What is New: • Swiss pediatric hospitals offer a wide range of pharmacological options for pain and anxiety management. However, significant barriers to PSA were identified. These include external control of intravenous sedation and insufficient integration of non-pharmacological interventions, such as child life specialists and procedural hypnosis. National guidelines are needed to harmonize PSA practices.

Procedural sedation competencies: a review and multidisciplinary international consensus statement on knowledge, skills, training, and credentialing

Procedural sedation is practised by a heterogeneous group of practitioners working in a wide array of settings. However, there are currently no accepted standards for the competencies a sedation practitioner should have, the content of sedation training programmes, and guidelines for credentialing. The multidisciplinary International Committee for the Advancement of Procedural Sedation sought to develop a consensus statement on the following: which competencies should medical or dental practitioners have for procedural sedation and how are they obtained, assessed, maintained, and privileged. Using the framework of Competency-Based Medical Education, the practice of procedural sedation was defined as a complex professional task requiring demonstrable integration of different competencies. For each question, the results of a literature review were synthetised into preliminary statements. Following an iterative Delphi review method, final consensus was reached. Using multispeciality consensus, we defined procedural sedation competence by identifying a set of core competencies in the domains of knowledge, skills, and attitudes across physical safety, effectiveness, psychological safety, and deliberate practice. In addition, we present a standardised framework for competency-based training and credentialing of procedural sedation practitioners.

Creating an Effective Simulation Environment

Simulation is a teaching and learning strategy that is used commonly in healthcare education in academia and practice settings. Nurses at the bedside may recall times in their formal education where simulation was used as a form of clinical learning or evaluation of their performance. It is possible that with the rise of nurse residency programs and in situ simulation that bedside nurses are experiencing simulation regularly within the workplace as a means of professional development. This article will set the stage for educators to develop high-quality simulation experiences.

Shaping the future of healthcare: improving quality and safety through integrating simulation into Public Health education

This perspective focuses on the role of healthcare simulation in training and implementing processes aimed at improving the quality of care and patient safety. Evidence of the effectiveness of simulation in improving clinical performance, reducing healthcare costs and raising professional education standards is presented. In light of this evidence, we propose to consider simulation-based education as an integrative training modality in the preparation of health professionals in the field of Public Health. A pilot project is presented with the aim of training professionals capable of further contributing to improving the quality and safety of patients through an interdisciplinary and innovative approach.

Implementation of a multi-site neonatal simulation improvement program: a cost analysis

BACKGROUND

To improve patient outcomes and provider team practice, the California Perinatal Quality Care Collaborative (CPQCC) created the Simulating Success quality improvement program to assist hospitals in implementing a neonatal resuscitation training curriculum. This study aimed to examine the costs associated with the design and implementation of the Simulating Success program.

METHODS

From 2017-2020, a total of 14 sites participated in the Simulating Success program and 4 of them systematically collected resource utilization data. Using a micro-costing approach, we examined costs for the design and implementation of the program occurring at CPQCC and the 4 study sites. Data collection forms were used to track personnel time, equipment/supplies, space use, and travel (including transportation, food, and lodging). Cost analysis was conducted from the healthcare sector perspective. Costs incurred by CPQCC were allocated to participant sites and then combined with site-specific costs to estimate the mean cost per site, along with its 95% confidence interval (CI). Cost estimates were inflation-adjusted to 2022 U.S. dollars.

RESULTS

Designing and implementing the Simulating Success program cost $228,148.36 at CPQCC, with personnel cost accounting for the largest share (92.2%), followed by program-related travel (6.1%), equipment/supplies (1.5%), and space use (0.2%). Allocating these costs across participant sites and accounting for site-specific resource utilizations resulted in a mean cost of $39,210.69 per participant site (95% CI: $34,094.52-$44,326.86). In sensitivity analysis varying several study assumptions (e.g., number of participant sites, exclusion of design costs, and useful life span of manikins), the mean cost per site changed from $35,645.22 to $39,935.73. At all four sites, monthly cost of other neonatal resuscitation training was lower during the program implementation period (mean = $1,112.52 per site) than pre-implementation period (mean = $2,504.01 per site). In the 3 months after the Simulating Success program ended, monthly cost of neonatal resuscitation training was also lower than the pre-implementation period at two of the four sites.

CONCLUSIONS

Establishing a multi-site neonatal in situ simulation program requires investment of sufficient resources. However, such programs may have financial and non-financial benefits in the long run by offsetting the need for other neonatal resuscitation training and improving practice.

Safety and quality in paediatric procedural sedation: what really matters?

PURPOSE OF REVIEW

This review gives an overview of the safety aspects for paediatric procedural sedation and a discussion of possibilities for optimizing structure, processes and outcomes.

RECENT FINDINGS

Procedural sedation in paediatric patients is performed by providers of different specialties and compliance with safety standards is a basic requirement regardless of provider specialty. This includes preprocedural evaluation, monitoring, equipment and profound expertise of sedation teams. The choice of sedative medications and the possibility of incorporating nonpharmacological methods play an important role for optimal outcome. In addition, an ideal outcome from the patient's perspective includes optimized processes and clear and empathetic communication.

SUMMARY

Institutions providing paediatric procedural sedation must ensure the comprehensive training of sedations teams. Furthermore, institutional standards for equipment, processes and optimal choice of medication depending on performed procedure and comorbidities of the patient must be established. At the same time, organizational and communication aspects should be considered.

Midazolam premedication in ileocolic intussusception: a retrospective multicenter study

Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001).

CONCLUSION

Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients.

WHAT IS KNOWN

• Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice.

WHAT IS NEW

• Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.

Children at risk of domestic accidents when are locked up at home: the other side of COVID-19 outbreak lockdown

Background

We proposed to analyze thoroughly the impact of the COVID-19 lockdown (CL) in changes of profiles and in trend of the domestic accidents (DAs) in children.

Methods

This was a single experience, cross-sectional study conducted at the emergency department (ED) of III trauma center. We enrolled children under 18 years admitted to ED with a diagnosis of DAs comparing the CL period from 10^th March 2020 to 4^th May 2020 with the same period of the previous year,10^th March 2019 to 4^th May 2019.

Results

In CL period, the cumulative incidence of ED visits for DAs increased from 86.88 to 272.13 per 1,000 children and the cumulative incidence of hospitalizations for DAs increased from 409.72 to 534.48 per 1,000 children. We reported in CL a decrease in the severity of ED presentation assessed by proxy measures: the level of priority ED visits reduced by 67% in CL period (OR: 0.33; 95%CI 0.22–0.48; p < 0.001); the likelihood of delayed time of presentation to ED increased by 65% in case of domestic injuries occurring in CL period (OR: 1.65; 95% CI: 1.17–2.34; p = 0.004); the odds of transfer from other hospital decreased by 78% in CL (OR: 0.15–0.33; p < 0.001). Children were more at risk of poisoning (OR:3.35–106.11; p = 0.001), of body foreign ingestion (OR: 1.83–14.39; p = 0.002) and less at risk of animal bite trauma (OR:0.05–0.35; p < 0.001).

Conclusion

Although the need to stay home has made a decisive breakthrough on the spread of COVID-19, the experience from this study underlines how this preventive measure has also had a downside in term of increased cumulative incidence of ED visits and of hospitalizations for DA.