The Effect of a Collaborative Pediatric Emergency Readiness Improvement Intervention on Patients' Hospital Outcomes

OBJECTIVE

We hypothesized that collaborative intervention to improve weighted pediatric readiness score (WPRS) will be associated with decreased pediatric intensive care (PICU) mortality, PICU and hospital length of stay.

METHODS

This study analyzes the transfer of acutely ill and injured patients from general emergency departments (GEDs) to our institution. The intervention involved customized assessment reports focusing on team performance and systems improvement for pediatric readiness, sharing best practices and clinical resources, designation of a nurse PECC at each GED and ongoing interactions at 2 and 4 months. Data was collected from charts before and after the intervention, focusing on patients transferred to our pediatric emergency department (ED) or directly admitted to our PICU from the GEDs. Clinical outcomes such as PICU length of stay (LOS), hospital LOS, and PICU mortality were assessed. Descriptive statistics were used for demographics, and various statistical tests were employed to analyze the data. Bivariate analyses and multivariable models were utilized to examine patient outcomes and the association between the intervention and outcomes.

RESULTS

There were 278 patients in the pre-intervention period and 314 patients in the post-intervention period. Multivariable analyses revealed a significant association between the change in WPRS and decreased PICU LOS (β=-0.05 [95% CI: -0.09, -0.01), p=0.023), and hospital LOS (β=-0.12 [95% CI: -0.21, -0.04], p=0.004), but showed no association between the intervention and other patient outcomes.

CONCLUSIONS

In this cohort, improving pediatric readiness scores in GEDs was associated with significant improvements in PICU and hospital length of stay. Future initiatives should focus on disseminating pediatric readiness efforts to improve outcomes of critically ill children nationally.

WHATS NEW

Improving pediatric readiness scores in general emergency departments is associated with improved downstream clinical outcomes demonstrated by reduced PICU and hospital length of stay.

The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments

OBJECTIVES

Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients.

METHODS

We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record.

RESULTS

Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09).

CONCLUSIONS

Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care.

Exploring cultural sensitivity during distance simulations in pediatric emergency medicine

Background

Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities.

Methods

This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups.

Results

Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of "how to practice PEM." The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement.

Conclusion

The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.

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.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments

OBJECTIVES

To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality.

METHODS

Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored.

RESULTS

A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores.

CONCLUSIONS

A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation

BACKGROUND

The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit.

METHODS

This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework.

RESULTS

Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized.

CONCLUSIONS

Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

Improving Emergency Preparedness in Pediatric Primary Care Offices: A Simulation-Based Interventional Study

OBJECTIVES

Pediatric emergencies pose a challenge to primary care practices due to irregular frequency and complexity. Simulation-based assessment can improve skills and comfort in emergencies. Our aim was improving pediatric office emergency preparedness, as measured by adherence to the existing American Academy of Pediatrics policy statement, and quality of emergency care in a simulated setting, as measured by performance checklists.

METHODS

This was a single center study nested in a multicenter, prospective study measuring emergency preparedness and quality of care in 16 pediatric primary care practices and consisted of 3 phases: baseline assessment, intervention, and follow-up assessment. Baseline emergency preparedness was measured by checklist based on AAP guidelines, and quality of care was assessed using in-situ simulation. A report-out was provided along with resources addressing potential areas for improvement after baseline assessment. A repeat preparedness and simulation assessment was performed after a 6 to 10 month intervention period to measure improvement from baseline.

RESULTS

Sixteen offices were recruited with 13 completing baseline and follow-up preparedness assessment. Eight of these sites also completed baseline and follow-up simulation assessment. Median baseline preparedness score was 70% and follow-up was 75.9%. Median baseline simulation performance scores were 37.4% and 35.5% for respiratory distress and seizure scenarios, respectively. Follow-up simulation assessment scores were 73% and 76.9% respectively (P = .001).

CONCLUSIONS

Our collaborative was able to successfully improve the quality of care in a simulated setting in a group of pediatric primary care offices over 6 to 10 months. Future work will focus on expansion and improving emergency preparedness.

The feasibility of a pediatric distance learning curriculum for emergency department nurses during the COVID-19 pandemic: An Improving Pediatric Acute Care Through Simulation (ImPACTS) collaboration

Introduction

To develop and evaluate the feasibility and effectiveness of a longitudinal pediatric distance learning curriculum for general emergency nurses, facilitated by nurse educators, with central support through the Improving Acute Care Through Simulation collaborative.

Methods

Kern’s 6-step curriculum development framework was used with pediatric status epilepticus aimed at maintaining physical distancing, resulting in a 12-week curriculum bookended by 1-hour telesimulations, with weekly 30-minute online asynchronous distance learning. Recruited nurse educators recruited a minimum of 2 local nurses. Nurse educators facilitated the intervention, completed implementation surveys, and engaged with other educators with the Improving Pediatric Acute Care through Simulation project coordinator. Feasibility data included nurse educator project engagement and curriculum engagement by nurses with each activity. Efficacy data were collected through satisfaction surveys, pre-post knowledge surveys, and pre-post telesimulation performance checklists.

Results

Thirteen of 17 pediatric nurse educators recruited staff to complete both telesimulations, and 38 of 110 enrolled nurses completed pre-post knowledge surveys. Knowledge scores improved from a median of 70 of 100 (interquartile range: 66-78) to 88 (interquartile range: 79-94) (P = .018), and telesimulation performance improved from a median of 60 of 100 (interquartile range: 45-60) to 100 (interquartile range: 85-100) (P = .016). Feedback included a shortened intervention and including physician participants.

Discussion

A longitudinal pediatric distance learning curriculum for emergency nurses collaboratively developed and implemented by nurse educators and Improving Pediatric Acute Care through Simulation was feasible for nurse educators to implement, led to modest engagement in all activities by nurses, and resulted in improvement in nurses’ knowledge and skills. Future directions include shortening intervention time and broadening interprofessional scope.

Comparison of a dichotomous versus trichotomous checklist for neonatal intubation

BACKGROUND

To compare validity evidence for dichotomous and trichotomous versions of a neonatal intubation (NI) procedural skills checklist.

METHODS

NI skills checklists were developed utilizing an existing framework. Experts were trained on scoring using dichotomous and trichotomous checklists, and rated recordings of 23 providers performing simulated NI. Videolaryngoscope recordings of glottic exposure were evaluated using Cormack-Lehane (CL) and Percent of Glottic Opening scales. Internal consistency and reliability of both checklists were analyzed, and correlations between checklist scores, airway visualization, entrustable professional activities (EPA), and global skills assessment (GSA) were calculated.

RESULTS

During rater training, raters gave significantly higher scores on better provider performance in standardized videos (both p < 0.001). When utilized to evaluate study participants' simulated NI attempts, both dichotomous and trichotomous checklist scores demonstrated very good internal consistency (Cronbach's alpha 0.868 and 0.840, respectively). Inter-rater reliability was higher for dichotomous than trichotomous checklists [Fleiss kappa of 0.642 and 0.576, respectively (p < 0.001)]. Sum checklist scores were significantly different among providers in different disciplines (p < 0.001, dichotomous and trichotomous). Sum dichotomous checklist scores correlated more strongly than trichotomous scores with GSA and CL grades. Sum dichotomous and trichotomous checklist scores correlated similarly well with EPA.

CONCLUSIONS

Neither dichotomous or trichotomous checklist was superior in discriminating provider NI skill when compared to GSA, EPA, or airway visualization assessment. Sum scores from dichotomous checklists may provide sufficient information to assess procedural competence, but trichotomous checklists may permit more granular feedback to learners and educators. The checklist selected may vary with assessment needs.

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation

Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings.

We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking.

Small groups (n = 121) and survey ranking (n = 54) were used with

This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation

Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings.

We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking.

Small groups (n = 121) and survey ranking (n = 54) were used with

This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of

Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center

OBJECTIVE

To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs.

STUDY DESIGN

A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected.

RESULTS

A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted.

CONCLUSIONS

Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.

Improving Pediatric Readiness and Clinical Care in General Emergency Departments: A Multicenter Retrospective Cohort Study

OBJECTIVE

To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs.

STUDY DESIGN

This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: postsimulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network's Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders.

RESULTS

A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention.

CONCLUSION

A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.

Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program

OBJECTIVES

The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.

METHODS

This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores.

RESULTS

A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline.

CONCLUSIONS

This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study

OBJECTIVES

Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices.

METHODS

This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated.

RESULTS

Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations.

CONCLUSIONS

Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND

The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training.

METHODS

This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument.

RESULTS

A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%).

CONCLUSIONS

This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

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.

Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department

This cross-sectional study assesses the association of race/ethnicity and other demographic factors with risk of receiving physical restraint during an emergency department (ED) visit.

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.].

Cost-effectiveness of a video game versus live simulation for disaster training

Introduction

Disaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training.

Methods

We synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC).

Results

The total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective.

Conclusions

A video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.

Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department

INTRODUCTION

Emergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists.

METHODS AND ANALYSIS

Our proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period.

ETHICS AND DISSEMINATION

Ethical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.

Telementoring for remote simulation instructor training and faculty development using telesimulation

Introduction

Simulation-based training is essential for high-quality medical care, but it requires access to equipment and expertise. Technology can facilitate connecting educators to training in simulation. We aimed to explore the use of remote simulation faculty development in Latvia using telesimulation and telementoring with an experienced debriefer located in the USA.

Methods

This was a prospective, simulation-based longitudinal study. Over the course of 16 months, a remote simulation instructor (RI) from the USA and a local instructor (LI) in Latvia cofacilitated with teleconferencing. Responsibility gradually transitioned from the RI to the LI. At the end of each session, students completed the Debriefing Assessment for Simulation in Healthcare (DASH) student version form (DASH-SV) and a general feedback form, and the LI completed the instructor version of the DASH form (DASH-IV). Outcome measures were the changes in DASH scores over time.

Results

A total of eight simulation sessions were cofacilitated of 16 months. As the role of the LI increased over time, the debrief quality measured with the DASH-IV did not change significantly (from 89 to 87), although the DASH-SV score decreased from a total median score of 89 (IQR 86–98) to 80 (IQR 78–85) (p=0.005).

Conclusion

In this study, telementoring with telesimulations resulted in high-quality debriefing. The quality—perceived by the students—was higher with the involvement of the remote instructor and declined during the transition to the LI. This concept requires further investigation and could potentially build local simulation expertise promoting sustainability of high-quality simulation.

Comparison of Two Telemedicine Delivery Modes for Neonatal Resuscitation Support: A Simulation-Based Randomized Trial

INTRODUCTION

Previous research has described technical aspects of telemedicine and the clinical impact of provider-to-patient telemedicine; however, little is known about provider-to-provider telemedical interventions.

OBJECTIVE

The primary aim of this study was to compare two telemedicine delivery modes on the quality of a simulated neonatal resuscitation. Our secondary aim was to evaluate the providers' task load.

METHODS

This was a prospective, single-center, randomized, simulation-based trial comparing a remote neonatal team leader ("teleleader") versus a remote consultant ("teleconsultant"). Participants resuscitated a simulated, apneic, and bradycardic neonate. Performance was assessed by video review and task load was measured by the self-reported NASA task load index (NASA-TLX) tool. In the teleleader group, one remote neonatal specialist assumed the role of team leader in the resuscitation. In the teleconsultant group, the same remote specialist assumed the role of teleconsultant.

RESULTS

Twenty-two participants were included in the analyses. The teleleader group was associated with a higher overall checklist score compared to teleconsultants (median score 68%, interquartile range [IQR]: 66-69 vs. 58%, IQR: 42-62; p = 0.016). No significant difference was seen in overall subjective workload as measured by the NASA-TLX tool. However, mental demand and frustration were significantly greater with teleconsultants compared to teleleaders (mean mental demand: 14.1 vs. 17.0 out of 21; frustration: 7.9 vs. 14.7 out of 21).

CONCLUSIONS

Simulated neonates randomized to teams with teleleaders received significantly better resuscitative care compared to those randomized to teams with teleconsultants. Mental demand and frustration were higher for providers in the teleconsultant compared to teleleader teams.

Impact of telemedicine on neonatal resuscitation in the emergency department: a simulation-based randomised trial

Background

The delivery and initial resuscitation of a newborn infant are required but rarely practised skills in emergency medicine. Deliveries in the emergency department are high-risk events and deviations from best practices are associated with poor outcomes.

Introduction

Telemedicine can provide emergency medicine providers real-time access to a Neonatal Resuscitation Program (NRP)-trained paediatric specialist. We hypothesised that adherence to NRP guidelines would be higher for participants with access to a remotely located NRP-trained paediatric specialist via telemedicine compared with participants without access.

Materials and methods

Prospective single-centre randomised trial. Emergency Medicine residents were randomised into a telemedicine or standard care group. The participants resuscitated a simulated, apnoeic and bradycardic neonate. In the telemedicine group a remote paediatric specialist participated in the resuscitation. Simulations were video recorded and assessed for adherence to guidelines using four critical actions. The secondary outcome of task load was measured through participants' completion of the NASA Task Load Index (NASA-TLX) and reviewers completed a detailed NRP checklist.

Results

Twelve participants were included. The use of telemedicine was associated with significantly improved adherence to three of the four critical actions reflecting NRP guidelines as well as a significant improvement in the overall score (p<0.001). On the NASA-TLX, no significant difference was seen in overall subjective workload assessment, but of the subscore components, frustration was statistically significantly greater in the control group (p<0.001).

Conclusions

In this study, telemedicine improved adherence to NRP guidelines. Future work is needed to replicate these findings in the clinical environment.

Recoding the metagenome: microbiome engineering in situ

Synthetic biology has enabled a new generation of tools for engineering the microbiome, including targeted antibiotics, protein delivery, living biosensors and diagnostics, and metabolic factories. Here, we discuss opportunities and limitations in microbiome engineering, focusing on a new generation of tools for in situ genetic modification of a microbiome that hold particular promise in circumventing these limitations.

Improving Simulated Pediatric Airway Management in Community Emergency Departments Using a Collaborative Program With a Pediatric Academic Medical Center

BACKGROUND

Pediatric airway management is a challenging process at community emergency departments (CEDs) due to lower pediatric volume, a lack of pediatric expertise among staff, and a lack of pediatric-specific equipment and resources. This has contributed to increased mortality in pediatric patients presenting to CEDs in comparison to pediatric academic medical centers (AMCs). We hypothesized that a collaborative program between CEDs and the state AMC would improve the quality of pediatric airway management provided by CEDs in simulated settings and the CEDs' pediatric emergency readiness scores.

METHODS

This prospective, pre- and post-intervention study utilized in situ simulation and was conducted in 10 CEDs in the state of Indiana. A team from the pediatric AMC led a multi-faceted improvement program, which included post-simulation debriefing, addressing pediatric airway management issues, targeted assessment reports, access to pediatric resources, and ongoing communication with the AMC. The primary outcome of the study was improvement of simulated pediatric airway management in the CEDs. The secondary outcome was improvement of the CEDs' pediatric emergency readiness scores score.

RESULTS

A total of 35 multidisciplinary teams participated in pre-intervention sessions, and 40 teams participated in post-intervention sessions. Overall adherence to a critical action checklist improved from 52% at the pre-intervention visits to 71% post-intervention (P = .003). There were significant improvements in the use of appropriate endotracheal tube (ETT) size (from 67% to 100%, P = .02), cuffed ETT (from 8% to 71%, P < .001), appropriate blade size (from 58% to 100%, P = .03), and availability of suction catheter (from 10% to 42%, P = .049). The CEDs' total pediatric emergency readiness scores score improved from 58.8 ± 15.6 pre-intervention to 75.8 ± 9.3 post-intervention (P = .01).

CONCLUSIONS

A collaborative improvement program between a pediatric AMC and CEDs improved the CEDs' simulated pediatric emergency airway management. This model can be utilized to improve management of other pediatric critical conditions in these CEDs.

The effect of an International competitive leaderboard on self-motivated simulation-based CPR practice among healthcare professionals: A randomized control trial

BACKGROUND

Little is known about how best to motivate healthcare professionals to engage in frequent cardiopulmonary resuscitation (CPR) refresher skills practice. A competitive leaderboard for simulated CPR can encourage self-directed practice on a small scale. The study aimed to determine if a large-scale, multi-center leaderboard improved simulated CPR practice frequency and CPR performance among healthcare professionals.

METHODS

This was a multi-national, randomized cross-over study among 17 sites using a competitive online leaderboard to improve simulated practice frequency and CPR performance. All sites placed a Laerdal® ResusciAnne or ResusciBaby QCPR manikin in 1 or more clinical units - emergency department, ICU, etc. - in easy reach for 8 months. These simulators provide visual feedback during 2-minute compressions-only CPR and a performance score. Sites were randomly assigned to the intervention for the first 4-months or the second 4-months. Following any CPR practice by a healthcare professional, participants uploaded scores and an optional 'selfie' photo to the leaderboard. During the intervention phase, the leaderboard displayed ranked scores and high scores earned digital badges. The leaderboard did not display control phase participants. Outcomes included CPR practice frequency and mean compression score, using non-parametric statistics for analyses.

RESULTS

Nine-hundred nineteen participants completed 1850 simulated CPR episodes. Exposure to the leaderboard yielded 1.94 episodes per person compared to 2.14 during the control phase (p = 0.99). Mean CPR performance participants did not differ between phases: 90.7 vs. 89.3 (p = 0.19).

CONCLUSION

A competitive leaderboard was not associated with an increase in self-directed simulated CPR practice or improved performance.

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

BACKGROUND AND OBJECTIVES

Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors.

METHODS

This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800-4,999; medium-high 5,000-9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence.

RESULTS

A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800-4,999/year), 24 medium-high (5,000-9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0-78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high-volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain.

CONCLUSIONS

This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high-volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations

Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival^© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study

BACKGROUND

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.

OBJECTIVES

To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.

METHODS

Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.

RESULTS

Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).

CONCLUSIONS

In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BACKGROUND

The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children.

OBJECTIVES

To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes.

METHODS

We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics.

RESULTS

From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%).

CONCLUSIONS

Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills

OBJECTIVES

Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy.

METHODS

This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks.

RESULTS

In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001).

CONCLUSION

60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.

A Collaborative In Situ Simulation-based Pediatric Readiness Improvement Program for Community Emergency Departments

BACKGROUND

More than 30 million children are cared for across 5,000 U.S. emergency departments (EDs) each year. Most of these EDs are not facilities designed and operated solely for children. A Web-based survey provided a national and state-by-state assessment of pediatric readiness and noted a national average score was 69 on a 100-point scale. This survey noted wide variations in ED readiness with scores ranging from 61 in low-pediatric-volume EDs to 90 in the high-pediatric-volume EDs. Additionally, the mean score at the state level ranged from 57 (Wyoming) to 83 (Florida) and for individual EDs ranged from 22 to 100. The majority of prior efforts made to improve pediatric readiness have involved providing Web-based resources and online toolkits. This article reports on the first year of a program that aimed to improve pediatric readiness across community hospitals in our state through in situ simulation-based assessment facilitated by our academic medical center. The primary aim was to improve the pediatric readiness scores in the 10 participating hospitals. The secondary aim was to explore the correlation of simulation-based performance of hospital teams with pediatric readiness scores.

METHODS

This interventional study measured the Pediatric Readiness Survey (PRS) prior to and after implementation of an improvement program. This program consisted of three components: 1) in situ simulations, 2) report-outs, and 3) access to online pediatric readiness resources and content experts. The simulations were conducted in situ (in the ED resuscitation bay) by multiprofessional teams of doctors, nurses, respiratory therapists, and technicians. Simulations and debriefings were facilitated by an expert team from a pediatric academic medical center. Three scenarios were conducted for all teams and include: a 6-month-old with respiratory failure, an 8-year-old with diabetic ketoacidosis (DKA), and a 6-month-old with supraventricular tachycardia (SVT). A performance score was calculated for each scenario. The improvement of PRS was compared before and after the simulation program. The correlation of the simulation performance of each hospital and the PRS was calculated.

RESULTS

Forty-one multiprofessional teams from 10 EDs in Indiana participated in the study, five were of medium pediatric volume and five were medium- to high-volume EDs. The PRS significantly improved from the first to the second on-site verification assessment (58.4 ± 4.8 to 74.7 ± 2.9, p = 0.009). Total adherence scores to scenario guidelines were 54.7, 56.4, and 62.4% in the respiratory failure, DKA, and SVT scenarios, respectively. We found no correlation between simulation performance and PRS scores. Medium ED pediatric volume significantly predicted higher PRS scores compared to medium-high pediatric ED volume (β = 8.7; confidence interval = 0.72-16.8, p = 0.034).

CONCLUSIONS

Our collaborative improvement program that involved simulation was associated with improvement in pediatric readiness scores in 10 EDs participating statewide. Future work will focus on further expanding of the network and establishing a national model for pediatric readiness improvement.

60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers

INTRODUCTION

Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game "60 Seconds to Survival" (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S.

METHODS

Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method.

RESULTS

There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335).

CONCLUSION

The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.

Safety Threats During the Care of Infants with Hypoglycemic Seizures in the Emergency Department: A Multicenter, Simulation-Based Prospective Cohort Study

BACKGROUND

Errors in the timely diagnosis and treatment of infants with hypoglycemic seizures can lead to significant patient harm. It is challenging to precisely measure medical errors that occur during high-stakes/low-frequency events. Simulation can be used to assess risk and identify errors.

OBJECTIVE

We hypothesized that general emergency departments (GEDs) would have higher rates of deviations from best practices (errors) compared to pediatric emergency departments (PEDs) when managing an infant with hypoglycemic seizures.

METHODS

This multicenter simulation-based prospective cohort study was conducted in GEDs and PEDs. In situ simulation was used to measure deviations from best practices during management of an infant with hypoglycemic seizures by inter-professional teams. Seven variables were measured: five nonpharmacologic (i.e., delays in airway assessment, checking dextrose, starting infusion, verbalizing disposition) and two pharmacologic (incorrect dextrose dose and incorrect dextrose concentration). The primary aim was to describe and compare the frequency and types of errors between GEDs and PEDs.

RESULTS

Fifty-eight teams from 30 hospitals (22 GEDs, 8 PEDs) were enrolled. Pharmacologic errors occurred more often in GEDs compared to PEDs (p = 0.043), while nonpharmacologic errors were uncommon in both groups. Errors more frequent in GEDs related to incorrect dextrose concentration (60% vs. 88%; p = 0.025), incorrect dose (20% vs. 56%; p = 0.033), and failure to start maintenance dextrose (33% vs. 65%; p = 0.040).

CONCLUSIONS

During the simulated care of an infant with hypoglycemic seizures, errors were more frequent in GEDs compared to PEDs. Decreasing annual pediatric patient volume was the best predictor of errors on regression analysis.

Screening residents for infant lumbar puncture readiness with just-in-time simulation-based assessments

Background

Determining when to entrust trainees to perform procedures is fundamental to patient safety and competency development.

Objective

To determine whether simulation-based readiness assessments of first year residents immediately prior to their first supervised infant lumbar punctures (LPs) are associated with success.

Methods

This prospective cohort study enrolled paediatric and other first year residents who perform LPs at 35 academic hospitals from 2012 to 2014. Within a standardised LP curriculum, a validated 4-point readiness assessment of first year residents was required immediately prior to their first supervised LP. A score ≥3 was required for residents to perform the LP. The proportion of successful LPs (<1000 red blood cells on first attempt) was determined. Process measures included success on any attempt, number of attempts, analgesia usage and use of the early stylet removal technique.

Results

We analysed 726 LPs reported from 1722 residents (42%). Of the 432 who underwent readiness assessments, 174 (40%, 95% CI 36% to 45%) successfully performed their first LP. Those who were not assessed succeeded in 103/294 (35%, 95% CI 30% to 41%) LPs. Assessed participants reported more frequent direct attending supervision of the LP (diff 16%; 95% CI 8% to 22%), greater use of topical analgesia (diff 6%; 95% CI 1% to 12%) and greater use of the early stylet removal technique (diff 11%; 95% CI 4% to 19%) but no difference in number of attempts or overall procedural success.

Conclusions

Simulation-based readiness assessments performed in a point-of-care fashion were associated with several desirable behaviours but were not associated with greater clinical success with LP.

Effects of alcohol-based hand hygiene solutions on breath alcohol detection in the emergency department

This study aimed to investigate the effects of alcohol-based hand hygiene solution (ABHS) use by care providers on point-of-care alcohol breath analyzer interpretation under different clinically relevant conditions. Among each test condition (foam vehicle with immediate testing, gel vehicle with immediate testing, allowing hands to dry after the use of ABHS, and donning gloves after the use of ABHS), alcohol was detected in breath at 1 minute after use of ABHS. Because the use of ABHS by individuals administering breath alcohol detection may result in false-positive detection of alcohol, staff using these devices should consider traditional hand hygiene with soap and water.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills

OBJECTIVE

Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT).

METHODS

Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK.

RESULTS

The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073).

CONCLUSION

This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments

IMPORTANCE

The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described.

OBJECTIVE

To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures.

DESIGN, SETTING, AND PARTICIPANTS

This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest).

MAIN OUTCOMES AND MEASURES

A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS.

RESULTS

Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001).

CONCLUSIONS AND RELEVANCE

This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.

What Parents Want: Does Provider Knowledge of Written Parental Expectations Improve Satisfaction in the Emergency Department?

OBJECTIVE

Satisfaction is an important measure of care quality. Interventions to improve satisfaction in the pediatric emergency department (ED) are limited, especially for patients with nonurgent conditions. Our objective was to determine if clinician knowledge of written parental expectations improves parental satisfaction for nonurgent ED visits.

METHODS

This randomized controlled trial was conducted in a tertiary-care pediatric ED. Parents of children presenting for nonurgent visits (Emergency Severity Index level 4 or 5) were randomized into 3 groups: 1) the intervention group completed an expectation survey on arrival, which was reviewed by the clinician, 2) the control group completed the expectation survey, which was not reviewed, and 3) the baseline group did not complete an expectation survey. At ED disposition, all groups completed a 3-item satisfaction survey, scored using 5-point Likert scales (1 = very poor, 5 = very good). The primary outcome was rating of "overall care." Secondary outcomes included likelihood of recommending the ED and staff sensitivity to concerns. Proportions were compared by chi-square test.

RESULTS

A total of 304 subjects were enrolled. The proportion of parents rating 5 of 5 for overall care did not differ among the baseline, control, and intervention groups (74.8% vs 73.2% vs 69.2%, P = .56). The proportion of parents rating 5 of 5 also did not differ for likelihood of recommending the ED (77.7% vs 72.2% vs 70.2%, P = .45) or staff sensitivity to concerns (78.6% vs 78.4% vs 78.8%, P = .71).

CONCLUSIONS

For nonurgent pediatric ED visits, clinician knowledge of written parental expectations does not improve parental satisfaction.

Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study

BACKGROUND

Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described.

OBJECTIVES

We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance.

METHODS

This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance.

RESULTS

We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88).

CONCLUSIONS

Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture

BACKGROUND AND OBJECTIVE

Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns' infant lumbar puncture (LP) success.

METHODS

This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009-2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010-2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts.

RESULTS

A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], -15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A.

CONCLUSIONS

Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP.

Structures of regulatory machinery reveal novel molecular mechanisms controlling B. subtilis nitrogen homeostasis

In Bacillus subtilis, nitrogen homeostasis is controlled by a unique circuitry composed of the regulator TnrA and the repressor GlnR. Here, Schumacher et al. describe a comprehensive molecular dissection of this network that reveals novel mechanisms, including oligomeric transformations, by which their inducible signal transduction domains are employed to provide a readout of nitrogen levels.

All cells must sense and adapt to changing nutrient availability. However, detailed molecular mechanisms coordinating such regulatory pathways remain poorly understood. In Bacillus subtilis, nitrogen homeostasis is controlled by a unique circuitry composed of the regulator TnrA, which is deactivated by feedback-inhibited glutamine synthetase (GS) during nitrogen excess and stabilized by GlnK upon nitrogen depletion, and the repressor GlnR. Here we describe a complete molecular dissection of this network. TnrA and GlnR, the global nitrogen homeostatic transcription regulators, are revealed as founders of a new structural family of dimeric DNA-binding proteins with C-terminal, flexible, effector-binding sensors that modulate their dimerization. Remarkably, the TnrA sensor domains insert into GS intersubunit catalytic pores, destabilizing the TnrA dimer and causing an unprecedented GS dodecamer-to-tetradecamer conversion, which concomitantly deactivates GS. In contrast, each subunit of the GlnK trimer “templates” active TnrA dimers. Unlike TnrA, GlnR sensors mediate an autoinhibitory dimer-destabilizing interaction alleviated by GS, which acts as a GlnR chaperone. Thus, these studies unveil heretofore unseen mechanisms by which inducible sensor domains drive metabolic reprograming in the model Gram-positive bacterium B. subtilis.

Structures of the Bacillus subtilis glutamine synthetase dodecamer reveal large intersubunit catalytic conformational changes linked to a unique feedback inhibition mechanism

Glutamine synthetase (GS), which catalyzes the production of glutamine, plays essential roles in nitrogen metabolism. There are two main bacterial GS isoenzymes, GSI-α and GSI-β. GSI-α enzymes, which have not been structurally characterized, are uniquely feedback-inhibited by Gln. To gain insight into GSI-α function, we performed biochemical and cellular studies and obtained structures for all GSI-α catalytic and regulatory states. GSI-α forms a massive 600-kDa dodecameric machine. Unlike other characterized GS, the Bacillus subtilis enzyme undergoes dramatic intersubunit conformational alterations during formation of the transition state. Remarkably, these changes are required for active site construction. Feedback inhibition arises from a hydrogen bond network between Gln, the catalytic glutamate, and the GSI-α-specific residue, Arg(62), from an adjacent subunit. Notably, Arg(62) must be ejected for proper active site reorganization. Consistent with these findings, an R62A mutation abrogates Gln feedback inhibition but does not affect catalysis. Thus, these data reveal a heretofore unseen restructuring of an enzyme active site that is coupled with an isoenzyme-specific regulatory mechanism. This GSI-α-specific regulatory network could be exploited for inhibitor design against Gram-positive pathogens.

Molecular basis for a protein-mediated DNA-bridging mechanism that functions in condensation of the E. coli chromosome

The E. coli chromosome is condensed into insulated regions termed macrodomains (MDs), which are essential for genomic packaging. How chromosomal MDs are specifically organized and compacted is unknown. Here, we report studies revealing the molecular basis for Terminus-containing (Ter) chromosome condensation by the Ter-specific factor MatP. MatP contains a tripartite fold with a four-helix bundle DNA-binding motif, ribbon-helix-helix and C-terminal coiled-coil. Strikingly, MatP-matS structures show that the MatP coiled-coils form bridged tetramers that flexibly link distant matS sites. Atomic force microscopy and electron microscopy studies demonstrate that MatP alone loops DNA. Mutation of key coiled-coil residues destroys looping and causes a loss of Ter condensation in vivo. Thus, these data reveal the molecular basis for a protein-mediated DNA-bridging mechanism that mediates condensation of a large chromosomal domain in enterobacteria.

Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes

INTRODUCTION

In an earlier study, Gatchel et al. (J Occup Rehabil 13:1-9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment.

METHODS

Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment.

RESULTS

At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care.

CONCLUSION

The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.