Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study

Management of Paediatric Cardiac Arrest due to Shockable Rhythm-A Simulation-Based Study at Children's Hospitals in a German Federal State

(1) Background: To improve the quality of emergency care for children, the Hessian Ministry for Social Affairs and Integration offered paediatric simulation-based training (SBT) for all children's hospitals in Hesse. We investigated the quality of paediatric life support (PLS) in simulated paediatric resuscitations before and after SBT. (2) Methods: In 2017, a standardised, high-fidelity, two-day in-house SBT was conducted in 11 children's hospitals. Before and after SBT, interprofessional teams participated in two study scenarios (PRE and POST) that followed the same clinical course of apnoea and cardiac arrest with a shockable rhythm. The quality of PLS was assessed using a performance evaluation checklist. (3) Results: 179 nurses and physicians participated, forming 47 PRE and 46 POST interprofessional teams. Ventilation was always initiated. Before SBT, chest compressions (CC) were initiated by 87%, and defibrillation by 60% of teams. After SBT, all teams initiated CC (p = 0.012), and 80% defibrillated the patient (p = 0.028). The time to initiate CC decreased significantly (PRE 123 ± 11 s, POST 76 ± 85 s, p = 0.030). (4) Conclusions: The quality of PLS in simulated paediatric cardiac arrests with shockable rhythm was poor in Hessian children's hospitals and improved significantly after SBT. To improve children's outcomes, SBT should be mandatory for paediatric staff and concentrate on the management of shockable rhythms.

Simulation based education in paediatric resuscitation

There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology - reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully.

Evaluation of Pediatric Readiness Using Simulation in General Emergency Departments in a Medically Underserved Region

BACKGROUND

Regionalization of pediatric care in the United States was developed to improve care by directing patients to hospitals with optimal pediatric resources and experience, leading to less pediatric-trained providers in medically underserved areas. Children with emergencies, however, continue to present to local general emergency departments (GEDs), where pediatric emergencies are low-frequency, high-risk events.

OBJECTIVE

The goals of this project were to: increase exposure of GEDs in the southeast United States to pediatric emergencies through simulation, assess pediatric emergency clinical care processes with simulation, describe factors associated with readiness including volume of pediatric patients and ED location (urban/rural), and compare these findings to the 2013 National Pediatric Readiness Project.

METHODS

This prospective in situ simulation study evaluated GED readiness using the Emergency Medical Services for Children Pediatric Readiness Score (PRS) and team performance in caring for 4 simulated pediatric emergencies. Comparisons between GED and pediatric ED (PED) performance and PRS, GED performance, and PRS based on pediatric patient volume and hospital location were evaluated. A Composite Quality Score (CQS) was calculated for each ED.

RESULTS

Seventy-five teams from 40 EDs participated (39 GED; 1 PED). The PED had a significantly higher volume of pediatric patients (73,000 vs 4492; P = 0.003). The PRS for GEDs was significantly lower (57% [SD, 17] vs 98%; P = 0.022). The CQSs for all GEDs were significantly lower than the PED (55% vs 87%; P < 0.004). Among GEDs, there was no statistically significant difference in PRS or CQS based on pediatric patient volume, but urban GEDs had significantly higher CQSs versus rural GEDs (59.8% vs 50.6%, P = 0.001).

CONCLUSIONS

This study shows a significant disparity in the performance and readiness of GEDs versus a PED in a medically underserved area. More education and better access to resources is needed in these areas to adequately care for critically ill pediatric patients.

Developing a virtual reality (VR) application for practicing the ABCDE approach for systematic clinical observation

BACKGROUND

The Airways, Breathing, Circulation, Disability, Exposure (ABCDE) approach is an international approach for systematic clinical observation. It is an essential clinical skill for medical and healthcare professionals and should be practiced repeatedly. One way to do so is by using virtual reality (VR). The aim was therefore to develop a VR application to be used by inexperienced health students and professionals for self-instructed practice of systematic clinical observation using the ABCDE approach.

METHODS

An iterative human-centred approach done in three overlapping phases; deciding on the ABCDE approach, specifying the requirements, and developing the application.

RESULTS

A total of 138 persons were involved. Eight clinical observations were included in the ABCDE approach. The requirements included making it possible for inexperienced users to do self-instructed practice, a high level of immersion, and a sense of presence including mirroring the physical activities needed to do the ABCDE approach, allowing for both single and multiplayer, and automatic feedback with encouragement to repeat the training. In addition to many refinements, the testing led to the development of some new solutions. Prominent among them was to get players to understand how to use the VR hand controllers and start to interact with the VR environment and more instructions like showing videos on how to do observations. The solutions in the developed version were categorised into 15 core features like onboarding, instructions, quiz, and feedback.

CONCLUSION

A virtual reality application for self-instructed practice of systematic clinical observation using the ABCDE approach can be developed with sufficient testing by inexperienced health students and professionals.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room

Background

Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum.

Methods

EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues.

Results

Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively.

Conclusions

Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.

Is in situ simulation in emergency medicine safe? A scoping review

OBJECTIVES

To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED).

DESIGN

Scoping review.

METHODS

Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine.

INFORMATION SOURCES

MEDLINE, EMBASE, Cochrane and Web of Science.

RESULTS

A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes.

CONCLUSION

Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.

GENESISS 2-Generating Standards for In-Situ Simulation project: a systematic mapping review

BACKGROUND

In-situ simulation is increasingly employed in healthcare settings to support learning and improve patient, staff and organisational outcomes. It can help participants to problem solve within real, dynamic and familiar clinical settings, develop effective multidisciplinary team working and facilitates learning into practice. There is nevertheless a reported lack of a standardised and cohesive approach across healthcare organisations. The aim of this systematic mapping review was to explore and map the current evidence base for in-situ interventions, identify gaps in the literature and inform future research and evaluation questions.

METHODS

A systematic mapping review of published in-situ simulation literature was conducted. Searches were conducted on MEDLINE, EMBASE, AMED, PsycINFO, CINAHL, MIDIRS and ProQuest databases to identify all relevant literature from inception to October 2020. Relevant papers were retrieved, reviewed and extracted data were organised into broad themes.

RESULTS

Sixty-nine papers were included in the mapping review. In-situ simulation is used 1) as an assessment tool; 2) to assess and promote system readiness and safety cultures; 3) to improve clinical skills and patient outcomes; 4) to improve non-technical skills (NTS), knowledge and confidence. Most studies included were observational and assessed individual, team or departmental performance against clinical standards. There was considerable variation in assessment methods, length of study and the frequency of interventions.

CONCLUSIONS

This mapping highlights various in-situ simulation approaches designed to address a range of objectives in healthcare settings; most studies report in-situ simulation to be feasible and beneficial in addressing various learning and improvement objectives. There is a lack of consensus for implementing and evaluating in-situ simulation and further studies are required to identify potential benefits and impacts on patient outcomes. In-situ simulation studies need to include detailed demographic and contextual data to consider transferability across care settings and teams and to assess possible confounding factors. Valid and reliable data collection tools should be developed to capture the complexity of team and individual performance in real settings. Research should focus on identifying the optimal frequency and length of in-situ simulations to improve outcomes and maximize participant experience.

A Cognitive Aid Improves Adherence to Guidelines for Critical Endotracheal Intubation in the Resuscitation Room: A Randomized Controlled Trial With Manikin-Based In Situ Simulation

INTRODUCTION

Emergency endotracheal intubation (ETI) is a high-risk procedure. Some of its adverse events are life-threatening, and guidelines emphasize the need to anticipate complications by thorough preparation. The emergency department (ED) can be an unpredictable environment, and we tested the hypothesis that a cognitive aid would help the emergency practitioners better follow guidelines. The main objective of this study was to determine whether the use of a cognitive aid focusing on both preintubation and postintubation items could improve ETI preparation and implementation in the ED resuscitation room regarding adherence to guidelines. The secondary objective was to measure and describe procedure times.

METHODS

We conducted a single-blind randomized controlled trial with manikin-based in situ simulation. The participants were not aware of the purpose of the study. The cognitive aid was developed using national guidelines and current scientific literature. The most relevant items were the preparation and implementation of a rapid sequence induction for ETI followed by mechanical ventilation. Emergency department physician-nurse pairs were randomized into a "cognitive aid" group and a "control" group. All pairs completed the same scenario that led to ETI in their own resuscitation room. An adherence to guidelines score of 30, derived from the 30 items of the cognitive aid (1 point per item), and preparation and intubation times were collected.

RESULTS

Seventeen pairs were included in each group. Adherence to guidelines scores were significantly higher in the cognitive aid group than in the control group (median = 28 of 30, interquartile range = 25-28, vs. median = 24 of 30, interquartile range = 21-26, respectively, P < 0.01). Preparation, intubation, and total procedure times were slightly longer in the cognitive aid group, but these results were not significant.

CONCLUSIONS

In an in situ simulation, a cognitive aid for the preparation and implementation of an emergency intubation procedure in the ED resuscitation room significantly improved adherence to guidelines without increasing procedure times. Further work is needed in a larger sample and in different settings to evaluate the optimal use of cognitive aids in critical situations.

Simulathon 2020: Integrating Simulation Period Prevalence Methodology Into the COVID-19 Disaster Management Cycle in India

SUMMARY STATEMENT

The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon , with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Projected Saudi Arabian pediatric emergency consultant physician staffing needs for 2021-2030

BACKGROUND

Assess current and future pediatric emergency physician supply and need at 26 pediatric emergency departments (EDs) in 10 administrative regions across Saudi Arabia from 2021 through 2030.

METHODS

For 10 administrative regions across Saudi Arabia, data were obtained on the size of the pediatric population (children <14 years old), the expected number of pediatric ED visits, and the number of pediatric emergency, fellowship-trained consultant physicians for the years 2015 through 2019. Time series linear regression modeling was used to estimate annual pediatric population sizes and pediatric ED visits for 2021-2030, based on 2015-2019 data trends. The projected number of pediatric emergency consultant physicians needed for 2021-2030 based on these trends was calculated according to a consensus method adopted by the Saudi Ministry of Health.

RESULTS

For the 10 Saudi Arabian administrative regions, the pediatric population is estimated to be 8,061,409 (95% confidence interval [CI]: 7,815,767 to 8,307,052) in 2021 and 9,764,591 (95% CI: 9,046,490 to 10,500,000) for 2030, and estimated the number of pediatric ED visits is 3,442,259 (95% CI: 3,013,697 to 3,870,822) for 2021 and 4,610,072 (95% CI: 3,026,986 to 6,193,158) for 2030. The projected number of pediatric emergency consultant physicians needed for 2021 is 1158 (95% CI: 1,002 to 1,314) and for 2030 is 1500 (95% CI: 985 to 2016), whereas deficit in number of pediatric emergency consultant physicians available is 1107 (95% CI: 944 to 1,270) for 2021 and 1405 (95% CI: 869 to 1,941) for 2030.

CONCLUSIONS

The study projections demonstrate a disparity between current and projected supply and demand of pediatric emergency physicians within Saudi Arabia.

Simulation-based assessment of care for infant cardiogenic shock in the emergency department

BACKGROUND

Congenital heart disease (CHD) is the leading cause of infant deaths associated with birth defects. Neonates with undiagnosed CHD often present to general emergency departments (GEDs) for initial resuscitation that are less prepared than paediatric centres, resulting in disparities in the quality of care. Neonates with undiagnosed CHD represent a challenge; thus, it is necessary for GEDs to be prepared for this population.

AIM

To evaluate the process of resuscitative care provided to a neonate in cardiogenic shock due to CHD in the GEDs in a simulated setting and to describe the impact of teams and GED variables on the process of care.

METHODS

This is a prospective simulation-based assessment of the process of care provided to a neonate with coarctation of the aorta in cardiogenic shock. Simulation sessions were conducted at participating GEDs utilizing each GED's interdisciplinary team and resources. The primary outcome was adherence to best practice, as measured by a 15-item overall composite adherence score (CAS). In addition, we stratified the overall CAS into CHD-critical items and the general resuscitation items CAS. The secondary outcome was the impact of the team's and GED's characteristics on the scores.

FINDINGS

This study enrolled 32 teams from 12 GEDs. Among 161 participants, 103 (63.97%) were registered nurses, 33 (20.50%) were physicians, 17 (10.56%) were respiratory therapists, and 8 (4.97%) were other medical professionals. The overall median CAS was 84, with the CHD-critical items having a median CAS of 34.5. The most underperformed tasks are checking pulses on the upper and lower extremities (44%), obtaining blood pressure in the upper and lower extremities (25%), and administering prostaglandin E1 (22%).

CONCLUSIONS

Using in situ simulation in a set of GEDs, we revealed gaps in the resuscitation care of neonates with CHD in cardiogenic shock.

RELEVANCE TO CLINICAL PRACTICE

These findings highlight the importance of targeted improvement programs for high-stakes illnesses in GED.

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 Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals

BACKGROUND

Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals.

METHODS

Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues.

RESULTS

Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues.

CONCLUSIONS

This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.

Impact of a shared decision-making mHealth tool on caregivers' team situational awareness, communication effectiveness, and performance during pediatric cardiopulmonary resuscitation: study protocol of a cluster randomized controlled trial

Background

Effective team communication, coordination, and situational awareness (SA) by team members are critical components to deliver optimal cardiopulmonary resuscitation (CPR). Complexity of care during CPR, involvement of numerous providers, miscommunication, and other exogenous factors can all contribute to negatively influencing patient care, thus jeopardizing survival. We aim to investigate whether an mHealth supportive tool (the Interconnected and Focused Mobile Apps on patient Care Environment [InterFACE]) developed as a collaborative platform to support CPR providers in real-time and share patient-centered information would increase SA during pediatric CPR.

Methods

We will conduct a prospective, cluster randomized controlled trial by groups of 6 participants in a tertiary pediatric emergency department (33,000 consultations/year) with pediatric physicians and nurses. We will compare the impact of the InterFACE tool with conventional communication methods on SA and effective team communication during a standardized pediatric in-hospital cardiac arrest and a polytrauma high-fidelity simulations. Forty-eight participants will be randomized (1:1) to consecutively perform two 20-min video-recorded scenarios using either the mHealth tool or conventional methods. The primary endpoint is the SA score, measured with the Situation Awareness Global Assessment Technique (SAGAT) instrument. Enrollment will start in late 2020 and data analysis in early 2021. We anticipate that the intervention will be completed by early 2021 and study results will be submitted in mid 2021 for publication.

Discussion

This clinical trial will assess the impact of a collaborative mHealth tool on increasing situational awareness and effective team communication during in-hospital pediatric resuscitation. As research in this area is scarce, the results generated by this study may become of paramount importance in improving the care of children receiving in-hospital CPR, in the era of increasing communication technology.

Trial registration

ClinicalTrials.gov NCT04464603. Registered on 9 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05170-3.

Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study

OBJECTIVE

To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs).

STUDY DESIGN

A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers.

RESULTS

Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline.

CONCLUSIONS

Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.

Simulation Training for Community Emergency Preparedness

Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [Pediatr Ann. 2021;50(1):e19-e24.].

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.

The Impact of a Tablet App on Adherence to American Heart Association Guidelines During Simulated Pediatric Cardiopulmonary Resuscitation: Randomized Controlled Trial

Background

Evidence-based best practices are the cornerstone to guide optimal cardiopulmonary arrest resuscitation care. Adherence to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite advances in resuscitation science and survival improvement over the last decades, only approximately 38% of children survive to hospital discharge after in-hospital cardiac arrest and only 6%-20% after out-of-hospital cardiac arrest.

Objective

We investigated whether a mobile app developed as a guide to support and drive CPR providers in real time through interactive pediatric advanced life support (PALS) algorithms would increase adherence to AHA guidelines and reduce the time to initiation of critical life-saving maneuvers compared to the use of PALS pocket reference cards.

Methods

This study was a randomized controlled trial conducted during a simulation-based pediatric cardiac arrest scenario caused by pulseless ventricular tachycardia (pVT). A total of 26 pediatric residents were randomized into two groups. The primary outcome was the elapsed time in seconds in each allocation group from the onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, including the time intervals between defibrillation attempts and drug doses, shock doses, and the number of shocks. All outcomes were assessed for deviation from AHA guidelines.

Results

Mean time to the first defibrillation attempt (121.4 sec, 95% CI 105.3-137.5) was significantly reduced among residents using the app compared to those using PALS pocket cards (211.5 sec, 95% CI 162.5-260.6, P<.001). With the app, 11 out of 13 (85%) residents initiated chest compressions within 60 seconds from the onset of pVT and 12 out of 13 (92%) successfully defibrillated within 180 seconds. Time to all other defibrillation attempts was reduced with the app. Adherence to the 2018 AHA pVT algorithm improved by approximately 70% (P=.001) when using the app following all CPR sequences of action in a stepwise fashion until return of spontaneous circulation. The pVT rhythm was recognized correctly in 51 out of 52 (98%) opportunities among residents using the app compared to only 19 out of 52 (37%) among those using PALS cards (P<.001). Time to epinephrine injection was similar. Among a total of 78 opportunities, incorrect shock or drug doses occurred in 14% (11/78) of cases among those using the cards. These errors were reduced to 1% (1/78, P=.005) when using the app.

Conclusions

Use of the mobile app was associated with a shorter time to first and subsequent defibrillation attempts, fewer medication and defibrillation dose errors, and improved adherence to AHA recommendations compared with the use of PALS pocket cards.

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.

Community-based in situ simulation: bringing simulation to the masses

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.

Prescription Opioid Use in General and Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES

Recent evidence reveals that exposure to emergency department (ED) opioids is associated with a higher risk of misuse. Pediatric EDs are generally thought to provide the highest-quality care for young persons, but most children are treated in general EDs. We sought to determine if ED opioid administration and prescribing vary between pediatric and general EDs.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey (2006-2015), a representative survey of ED visits, by using multivariate logistic regressions. Outcomes of interest were the proportion of patients ≤25 years of age who (1) were administered an opioid in the ED, (2) were given a prescription for an opioid, or (3) were given a prescription for a nonopioid analgesic. The key predictor variable was ED type. A secondary analysis was conducted on the subpopulation of patients with a diagnosis of fracture or dislocation.

RESULTS

Of patients ≤25 years of age, 91.1% were treated in general EDs. The odds of being administered an opioid in the ED were similar in pediatric versus general EDs (adjusted odds ratio [OR] 0.88; 95% confidence interval [CI] 0.61-1.27; P = .49). Patients seen in pediatric EDs were less likely to receive an outpatient prescription for opioids (adjusted OR 0.38; 95% CI 0.27-0.52; P < .01) than similar patients in general EDs. This was true for the fracture subset as well (adjusted OR 0.27; 95% CI 0.13-0.54; P < .01).

CONCLUSIONS

Although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they were much less likely to receive an opioid prescription from a pediatric ED compared with a general ED.

Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.