COVID-19 Pneumonia and Status Asthmaticus With Respiratory Failure in a Pediatric Patient: A Simulation for Emergency Medicine Providers

INTRODUCTION

During COVID-19 surges, medical trainees may perform patient care outside typical clinical responsibilities. While respiratory failure in pediatric patients secondary to COVID-19 is rare, it is critical that providers can effectively care for these children while protecting the health care team. Simulation is an important tool for giving learners a safe environment in which to learn and practice these new skills.

METHODS

In this simulation, learners provided care to a 13-year-old male with obesity, COVID-19 pneumonia, status asthmaticus, and respiratory failure. Target learners were pediatric emergency medicine fellows and emergency medicine residents. Providers were expected to identify the signs and symptoms of status asthmaticus, pneumonia, and respiratory failure and demonstrate appropriate evaluation and management while minimizing COVID-19 exposure. Participants completed a postsimulation survey on their satisfaction and confidence in performing the objectives.

RESULTS

Twenty-eight PGY 1-PGY 6 learners participated in this simulation. The postsimulation survey showed that most learners felt the simulation was effective in teaching the evaluation and management of respiratory failure due to COVID-19 (M = 5.0; 95% CI, 4.9-5.0) and was relevant to their work (M = 5.0; 95% CI, 5.0-5.0).

DISCUSSION

Learners felt that the case was effective in teaching the skills needed to care for a child with COVID-19 pneumonia, status asthmaticus, and respiratory failure. Future directions include updating the case with new COVID-19 knowledge and personal protective equipment practices gained over time, using hybrid telesimulation to increase learners' exposure to the case, and adapting the case for other health care providers.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Diabetic Ketoacidosis

INTRODUCTION

Diabetic ketoacidosis (DKA) is a life-threatening illness which classically presents with polyuria, polydipsia, and polyphagia that can rapidly progress to severe dehydration and altered mental status from cerebral edema. Younger patients may present with subtle or atypical symptoms that are critical to recognize and emergently act upon. Such patients are often cared for by teams in the emergency department (ED) requiring multidisciplinary collaboration.

METHODS

This simulation case was designed for pediatric emergency medicine fellows and residents. The case was a 14-month-old male who presented to the ED with respiratory distress and dehydration. The team was required to perform an assessment, manage airway, breathing and circulation, and recognize and initiate treatment for DKA including judicious fluid administration and an insulin infusion. The patient developed altered mental status with signs of cerebral edema requiring the initiation of cerebral protection strategies. We created a debriefing guide and a participant evaluation form.

RESULTS

Forty-two participants completed this simulation across seven institutions including attendings, residents, fellows, and nurses. The scenario was rated by participants on a 5-point Likert scale and was generally well received (M = 5.0). Participants rated the simulation case as effective in teaching how to recognize (M = 4.8) and manage (M = 4.5) DKA with cerebral edema in a pediatric patient.

DISCUSSION

This simulation represents a resource for learners in the pediatric ED in the recognition and management of a toddler with DKA and can be adapted to learners at all levels and tailored to various learning environments.

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn

INTRODUCTION

The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB.

METHODS

This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials.

RESULTS

The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management.

DISCUSSION

This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Teaching Pediatric Palliative Care Communication Skills to Fourth-Year Medical Students Through Role-Play

INTRODUCTION

Despite growing recognition of pediatric palliative care's importance, training in palliative care communication remains a gap in medical education. Graduating medical students frequently feel unprepared to initiate or facilitate goals of care conversations with their patients, particularly in pediatrics.

METHODS

We created a 3-hour session featuring an introductory lecture on pediatric palliative care, communication drills on responding to emotion, and small-group case-based discussions utilizing role-play, targeting fourth-year medical students as the primary learners. Senior residents were also given the opportunity to develop skills by role-playing the patient parent and cofacilitating case discussions alongside palliative care faculty. Students evaluated session utility and their own confidence through pre- and postsession surveys using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).

RESULTS

Twenty-six students were included in the analysis over 3 years. All agreed that the session was useful (M = 4.9). Students showed significant improvement in confidence in explaining pediatric palliative care (presession M = 3.2, postsession M = 4.1, p < .001), understanding the family experience (presession M = 2.7, postsession M = 4.1, p < .001), and eliciting goals and values from families whose children face serious illnesses (presession M = 3.1, postsession M = 4.1, p < .001). Pediatric resident cofacilitators also felt the session benefited their own teaching and communication skills.

DISCUSSION

This 3-hour interactive session on pediatric palliative care utilizing communication drills and role-play was effective in improving fourth-year medical students' confidence in communicating with families of children facing life-threatening illnesses.

Pediatric Intensive Care Unit Resident Educational Curriculum

INTRODUCTION

Consistent medical knowledge acquisition while caring for the critically ill can be challenging for learners and educators in the pediatric intensive care unit (PICU), a unit often distinguished by fluctuating acuity and severity. We implemented a standardized didactic curriculum for PICU residents to facilitate their acquisition and retention of knowledge in core PICU topics.

METHODS

We developed a comprehensive standardized curriculum for PGY 2-PGY 4 PICU pediatric and internal medicine-pediatric residents. Thirteen core topics were administered as 30-minute didactic sessions during the rotation, using either PowerPoint slides or a dry-erase board. Residents were tested to assess knowledge acquisition and retention.

RESULTS

Seventy-eight residents participated, 86% of whom completed posttests. Seventeen percent completed follow-up tests. Of the learners who participated, 60 (77%) completed pretests and posttests, indicating their confidence level each time. The pretest mean was 55% (SD = 14.4%), and the posttest mean was 64% (SD = 15.6%). This 9% increase was statistically significant (p = .001; CI, 3.9% to 14.8%). The follow-up test at 3 months, completed by 15% of this subgroup, demonstrated a mean score of 62% (SD = 14.5%). When matched with posttest scores (mean score of 64%, SD = 13.3%), there was no significant difference (p = .7398; CI, -11.7% to 16.2%), suggesting retention of previously acquired knowledge.

DISCUSSION

Our standardized didactic curriculum effectively facilitated the acquisition and retention of the medical knowledge of core PICU topics among PICU residents, in addition to their usual experiential learning.

"When in Doubt, Change It out": A Case-Based Simulation for Pediatric Residents Caring for Hospitalized Tracheostomy-Dependent Children

INTRODUCTION

Caring for technology-dependent children, such as those with tracheostomy and ventilator dependence, can be new and frightening for pediatric residents. Education about emergencies in this patient population is important because these children are at risk for in-hospital complications. Safe care of the tracheostomy-dependent child requires the ability to recognize common complications, such as tracheostomy tube obstruction or decannulation, and intervene appropriately by suctioning and/or replacing the tracheostomy tube. This simulation-based curriculum teaches learners to identify and practice the management of these tracheostomy tube complications through low-fidelity simulation exercises.

METHODS

We created a simulation session with three cases reflecting in-hospital scenarios encountered by resident physicians caring for tracheostomy-dependent children in the inpatient setting. The simulation scenario, simulation environment preparation, materials list, and debriefing outline are provided for the instructor for each simulation case. Validity evidence for the assessment tool was obtained by calculating the interrater reliability of two different raters. Resident feedback was obtained through anonymous surveys.

RESULTS

Twelve pediatric senior residents completed the experience. It received overwhelmingly positive feedback on learner evaluation forms, with 90% finding the experience very or extremely helpful. The intraclass correlation coefficient of interrater reliability for our assessment tool was 0.93.

DISCUSSION

The simulation was well received by residents. The interrater reliability was acceptable. This low-fidelity simulation exercise can easily be executed with minimal materials or instructor training. High-yield, just-in-time training with postcase debriefing is key to the simulation's success.

Excellence in Communication and Emergency Leadership (ExCEL): Pediatric First 5 Minutes Workshop for Residents

INTRODUCTION

In-hospital pediatric cardiopulmonary arrest is associated with high morbidity and mortality, and appropriate initial management has been associated with improved clinical outcomes. Despite current training, pediatric residents often do not feel confident in their ability to deliver this initial management. This workshop focused on the initial management of critically ill pediatric patients and performance of high-quality CPR.

METHODS

This hands-on workshop utilized skill stations with low- and medium-fidelity simulators to instruct learners on initial management during the first 5 minutes of a code, including high-quality CPR. It was designed for residents across all levels of training who care for pediatric patients (including pediatrics, medicine-pediatrics, pediatrics, psychiatry, and child psychiatry, family medicine, and emergency medicine residents) and can be adapted for different session durations and group sizes.

RESULTS

This workshop was conducted at two separate institutions with a total of 18 resident participants. Participants strongly agreed that this workshop was relevant and effective in teaching the initial assessment and management of the critical pediatric patient, including how to best perform high-quality CPR. Residents further reported high levels of confidence in initially assessing and managing a critically ill patient, describing the markers of high-quality CPR, and performing high-quality CPR.

DISCUSSION

This workshop provided residents with additional instruction and practice in the initial management of critically ill pediatric patients in cardiopulmonary arrest. The structure and timeline of this curriculum can be adapted to the needs of the individual institution's program and the number of workshop participants.

High-Fidelity Simulation Scenario: Pediatric Sulfonylurea Overdose and Treatment

INTRODUCTION

Oral antidiabetic medications are becoming increasingly popular as the incidence of type II diabetes mellitus increases. Overdoses of these medications, either intentional or accidental, can be detrimental if not quickly recognized and treated. One of the most common classes of hypoglycemic oral antidiabetics, sulfonylureas, was discussed in this case.

METHODS

We designed this high-fidelity simulation to help increase the learner's knowledge of sulfonylurea overdoses, including recognizing signs/symptoms, management, and disposition. This simulation was designed to be used with fourth-year medical students, emergency medicine residents, and pediatric residents. The case involves a previously healthy 3-year-old male presenting with altered mental status and seizures secondary to glyburide ingestion. A standard pediatric simulation mannequin was required. The patient presented with altered mental status and began seizing upon arrival. After a thorough history, glyburide ingestion was identified. Critical actions included obtaining a fingerstick glucose measurement, determining an appropriate concentration of dextrose, starting a dextrose drip, and admission for further management.

RESULTS

This simulation case was performed at the simulation lab at SUNY Upstate Medical University by a combination of 83 fourth-year medical students, and emergency medicine and pediatric residents. Feedback and evaluations for the case showed it improved medical education and clinical skills.

DISCUSSION

This simulation was well received and helped participants develop a better understanding of sulfonylurea overdose identification. It also improved participants' ability to manage refractory hypoglycemia and compile a more comprehensive list of differential diagnoses.

Pathophysiology for the Pediatric Critical Care Fellow: Three Representative Simulation Cases

INTRODUCTION

During the course of fellowship training, pediatric critical care fellows are expected to develop a broad and in-depth understanding of the pathophysiology of multiple disease processes. The simulation-based pediatric critical care pathophysiology curriculum we present uses scenarios created by pediatric critical care fellows to teach complex pathophysiology.

METHODS

Each of the three representative cases presented covered a specific pathophysiologic process and required participants to acutely manage (1) an 18-year-old patient with altered mental status in the setting of hepatic encephalopathy; (2) an 8-year-old patient with sepsis, coagulopathy, and acute kidney injury; or (3) a 12-year-old patient with status epilepticus. Each case could be conducted in a simulation suite or an acute care unit bed. We assessed learners' knowledge and attitudes at the end of these simulations with a structured debriefing session and via completion of an evaluation form. The simulations were then followed by a 30-minute interactive didactic session on the topic.

RESULTS

Each scenario had six fellow participants who completed evaluations. After completing each of the three case scenarios presented, the majority of participating pediatric critical care fellows indicated that the content was relevant and sufficiently challenging. They also indicated that these simulation scenarios would improve their clinical practice.

DISCUSSION

This fellow-developed simulation curriculum is novel, highlighting the relevance for critical care fellows' understanding of realistic clinical scenarios while promoting advanced management skills with a pathophysiology focus.

Chasing Fevers: An Interactive Exercise for Pediatrics Residents on Triaging and Assessing Inpatients With Fever

INTRODUCTION

Pediatrics residents are frequently tasked with triaging fevers in pediatric inpatients. The variety of clinical scenarios in the inpatient setting-patients with a multitude of diseases and a spectrum of risk for invasive infection-makes this task challenging. To enhance our residents' training on this topic, we developed an activity providing explicit instruction on how to approach these patient scenarios.

METHODS

The 45-minute activity began with an interactive discussion on approaching pediatric inpatient fevers, followed by a case-based exercise where small groups were assigned one of six clinical scenarios involving inpatients with fever. Learners discovered new information about their patient by drawing paper slips out of a container. Each slip could take their patient's story in a different direction. Small groups discussed decision-making options for their assigned case at each step. Among the potential events were rapid response calls-acute issues requiring immediate assessment-in which learners competed for limited seats to determine who would respond to the call. The activity concluded with a discussion about treatment of inpatient fevers.

RESULTS

Respondents to the postevent evaluation rated the activity as highly engaging, effective in helping them achieve its learning objectives, highly relevant to their career, and effective in simulating real-life clinical decision-making situations.

DISCUSSION

This instructional technique offers a unique, engaging, case-based approach to teaching about inpatient fever management in which instructors facilitate and support learners' articulation of clinical reasoning. Future directions include using this technique for other common clinical problems and with other learner groups.

Critical Cardiopulmonary Event Series: Four Simulations for Pediatric ICU Fellows, Critical Care Nurses, and Pediatric Residents

INTRODUCTION

Critical cardiopulmonary events arising from congenital or acquired heart diseases are infrequent in some pediatric critical care units but can be associated with significant morbidity and mortality when encountered. We developed four simulation cases for interprofessional pediatric critical care teams (fellows, residents, and nurses) to provide participants with high-acuity cardiopulmonary scenarios in safe learning environments. The included cases were coarctation of the aorta, Kawasaki disease, myocarditis, and tetralogy of Fallot.

METHODS

The simulations were typically 15 minutes in duration and took place within the pediatric intensive care unit. The scenarios began with handoff of the patient to the primary nurse, who recruited the assistance of resident physicians and ultimately a pediatric critical care medicine fellow as the scenario escalated. Upon completion, participants engaged in a structured, interactive debriefing session for 40 minutes. Afterward, they were asked to complete an anonymous feedback form that was collected and analyzed.

RESULTS

Based on aggregate postsimulation survey responses from 114 learners, participants reported that these simulation exercises improved their knowledge and ability to manage acutely deteriorating cardiac patients. Additionally, learners rated the impact of the simulation on their practice highly (average score >4 for each group of participants on a 5-point Likert scale). Feedback was analyzed and categorized into three domains: (1) Pediatric Medicine Learning Objectives, (2) Teamwork Strategies, and (3) Opportunities for Simulation Improvements.

DISCUSSION

This series advances self-reported learner knowledge and skills surrounding management of cardiopulmonary events while also providing opportunities to enhance teamwork and communication skills.