Public knowledge of button battery ingestions: A social media based cross-sectional analysis.

INTRODUCTION: Button battery (BB) ingestion injuries are a devastating and preventable event within the pediatric population. Efforts to reduce the prevalence of esophageal button battery ingestion injuries include primary preventative measures. It is integral to assess the public's baseline knowledge about BB injuries to tailor future primary prevention efforts. METHODS: This is a crowdsourcing survey-based study. Participants were notified through our institution's Twitter and Instagram accounts. RESULTS: There were 930 completed survey responses from May to June 2022. The survey found that 87% (791/910) knew that swallowing a BB could cause injury and 71% knew that it could cause death (642/905). Eight-five percent of respondents did not know what signs and symptoms to look for after BB ingestion, only 30% (99/340) of healthcare professionals felt they would know. Only 10.1% (94/930) of participants knew to give children over 12 months old honey after suspected BB ingestion. Thirty-four percent (311/930) knew that complications could still occur even after BB were removed. Seventy-seven percent (719/930) knew that a dead BB could cause injury but only 17% knew the correct way to dispose of a dead button battery (158/930). Only 8% (72/930) of participants were knew that wrapping dead BB in tape could potentially prevent injury. CONCLUSION: The current study reveals gaps in the public's understanding of BB injury including: the presentation of BB injuries; the delayed harm of BB impactions; management and mitigation strategies, and BB disposal methods. This survey provided imperative insights to help guide future education and primary prevention initiatives.

Deep Learning Model for Automated Trainee Assessment During High-Fidelity Simulation.

PROBLEM: Implementation of competency-based medical education has necessitated more frequent trainee assessments. Use of simulation as an assessment tool is limited by access to trained examiners, cost, and concerns with interrater reliability. Developing an automated tool for pass/fail assessment of trainees in simulation could improve accessibility and quality assurance of assessments. This study aimed to develop an automated assessment model using deep learning techniques to assess performance of anesthesiology trainees in a simulated critical event. APPROACH: The authors retrospectively analyzed anaphylaxis simulation videos to train and validate a deep learning model. They used an anaphylactic shock simulation video database from an established simulation curriculum, integrating a convenience sample of 52 usable videos. The core part of the model, developed between July 2019 and July 2020, is a bidirectional transformer encoder. OUTCOMES: The main outcome was the F1 score, accuracy, recall, and precision of the automated assessment model in analyzing pass/fail of trainees in simulation videos. Five models were developed and evaluated. The strongest model was model 1 with an accuracy of 71% and an F1 score of 0.68. NEXT STEPS: The authors demonstrated the feasibility of developing a deep learning model from a simulation database that can be used for automated assessment of medical trainees in a simulated anaphylaxis scenario. The important next steps are to (1) integrate a larger simulation dataset to improve the accuracy of the model; (2) assess the accuracy of the model on alternative anaphylaxis simulations, additional medical disciplines, and alternative medical education evaluation modalities; and (3) gather feedback from education leadership and clinician educators surrounding the perceived strengths and weaknesses of deep learning models for simulation assessment. Overall, this novel approach for performance prediction has broad implications in medical education and assessment.

Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review.

CONTEXT: Children presenting to health care facilities with button battery (BB) impaction. OBJECTIVES: To describe characteristics of children with vascular complications after BB impaction, as well as associated outcomes. DATA SOURCES: National Capital Poison Center registry and PubMed database from inception to December 2021. STUDY SELECTION: All reports describing children aged <18 years with vascular, esophageal, or airway complications after BB ingestion. DATA EXTRACTION: We extracted characteristics including date of publication, age and sex of child, battery type and size, duration and location of impaction, complications, subsequent interventions, and interval between battery removal and death. RESULTS: A total of 361 cases involved severe complications or death after BB ingestion (321 cases from the National Capital Poison Center registry database, 40 additional cases from PubMed). Nineteen percent (69 of 361) were fatal and 14% (51 of 361) involved vascular injuries. Three-quarters (75%) of vascular complications were aorto-esophageal fistulae and 82% of vascular injuries were not survivable. Fatal vascular cases had significantly longer median impaction time (96 hours versus 144 hours, P <.05) and a wider range of presenting features than survivors. LIMITATIONS: The total number of cases with vascular complications was small, data reported varied between cases, and no data were available on overall exposure. Long-term morbidity data were not available for the survivors. CONCLUSIONS: Prolonged BB impaction is a risk factor for vascular complications and death. A high index of suspicion is required for children representing with hematemesis after BB impaction, with prompt transfer to a tertiary center because vascular surgical intervention may offer a chance of survival.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review.

Importance: Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions. Objective: To review airway injuries, including long-term sequelae, after BB ingestion in children. Evidence Review: For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis. Conclusions and Relevance: Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Button battery taping prevents oesophageal injury.

AIM: Most button battery (BB) ingestions in children are unwitnessed leading to prolonged exposures and severe complications. One third of ingestions occur from free BB, that are stored or awaiting disposal. Recommendations have been made to cover the terminals of discarded BB with adhesive tape; however, it is unclear if this practice prevents injury. Our aim was to determine if tape could prevent oesophageal injury in a cadaveric porcine model. METHODS: Electrical, masking, packing and duct tape were compared. One BB was left untaped. Taped BBs were placed in a cadaveric porcine oesophagus controlled for temperature and humidification. Specimens were assessed at 0, 0.5, and hourly for 6 h by visual inspection, temperature and pH. BB voltage was measured before and after testing. All tests were repeated in triplicate. RESULTS: Oesophageal specimens demonstrated burn prevention in the packing and duct tape trials. Burns were seen in 2/3 trials with electrical tape and 3/3 trials with masking tape. pH remained neutral throughout the study for all packing and duct tape specimens. pH remained neutral initially for masking tape but increased rapidly to 12 by 2 h. There was no change in battery voltage for the packing tape and duct tape trials. There was a 16.3% reduction in voltage for masking tape which was similar to controls. CONCLUSIONS: Taping BB with packing tape and duct tape prevented oesophageal burns. This may provide a novel method of burn prevention for loose BB intended for disposal.

Feasibility of ultrasound-assisted lumbar punctures performed by pediatric oncologists at the point of care.

BACKGROUND: Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer. Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure. METHODS: Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound. RESULTS: All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/µl, and nine (16%) had ≥10 RBCs/µl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful. CONCLUSIONS: Pediatric oncologists readily achieved competence in ultrasound-assisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.

Simulation-based assessment in anesthesia: an international multicentre validation study.

PURPOSE: Simulated clinical events provide a means to evaluate a practitioner's performance in a standardized manner for all candidates that are tested. We sought to provide evidence for the validity of simulation-based assessment tools in simulated pediatric anesthesia emergencies. METHODS: Nine centres in two countries recruited subjects to participate in simulated operating room events. Participants ranged in anesthesia experience from junior residents to staff anesthesiologists. Performances were video recorded for review and scored by specially trained, blinded, expert raters. The rating tools consisted of scenario-specific checklists and a global rating scale that allowed the rater to make a judgement about the subject's performance, and by extension, preparedness for independent practice. The reliability of the tools was classified as "substantial" (intraclass correlation coefficients ranged from 0.84 to 0.96 for the checklists and from 0.85 to 0.94 for the global rating scale). RESULTS: Three-hundred and ninety-one simulation encounters were analysed. Senior trainees and staff significantly out-performed junior trainees (P = 0.04 and P < 0.001 respectively). The effect size of grade (junior vs senior trainee vs staff) on performance was classified as "medium" (partial η2 = 0.06). Performance deficits were observed across all grades of anesthesiologist, particularly in two of the scenarios. CONCLUSIONS: This study supports the validity of our simulation-based anesthesiologist assessment tools in several domains of validity. We also describe some residual challenges regarding the validity of our tools, some notes of caution in terms of the intended consequences of their use, and identify opportunities for further research.

Impact of Critical Event Checklists on Anaesthetist Performance in Simulated Operating Theatre Emergencies.

Introduction Crises in the operating theatre during a paediatric case are rare with the incidence of anesthesia-related cardiac arrest in non-cardiac patients being 1.4/10,000. In order to address this, the Society for Pediatric Anesthesia (SPA) developed cognitive aids (CAs) in the form of Critical Event Checklists (SPA CECs). Several studies have demonstrated the benefit of CAs in improving performance of critical tasks. Despite the presence of CAs, individuals often do not use the aids consistently. The objective of our study was to investigate whether the presence of SPA CECs, and orientation to these tools, improve the performance of trainees during simulated critical events. Methods With local Research Ethics Board (REB) approval we used a randomized, 2 x 2 factorial design. The first randomization was the participant orientation to the SPA CECs (e-module vs. didactic). The second randomization assigned participants to complete the simulations with or without SPA CECs available. The simulations were videoed and rated by two raters using a scenario-specific checklist and global rating scale (GRS). Results We conducted 78 simulations. The SPA CEC was used in 17.9% of scenarios. The SPA CEC was used in 44.8% of diagnosis-based scenarios and only 2.0% of generic problem-based scenarios. Participants' performance was superior with the SPA CEC present (GRS mean 3 [SD 1.27]) than without the SPA CEC available (GRS mean 2.43 [SD 0.89]) (p = 0.048). Conclusion Overall, we showed that uptake of the SPA CECs is poor. We also demonstrated that when the SPA CECs are utilized, they enhance the performance of trainees in simulated operating room (OR) critical events.

Use of Serratus Plane Block for Repair of Coarctation of Aorta: A Report of 3 Cases.

OBJECTIVES: The practice of regional anesthesia techniques (thoracic, epidural, paravertebral) in pediatric cardiac surgery enhances perioperative outcomes such as improved perioperative analgesia, decreased stress response, early extubation, and shortened hospital stay. However, these blocks can be technically challenging and can be associated with unacceptable failure rate and complications in infants. For these reasons, regional anesthesia is sometimes avoided in pediatric cardiac surgery. We describe the simple and effective serratus plane block for thoracotomy analgesia in 2 neonates and a child. CASE REPORT: We present 3 pediatric patients, each of whom was having coarctation repair and received an ultrasound-guided serratus plane block for thoracotomy analgesia. The patients were 3 days, 14 days, and 4 years old, weighing from 1.9 to 16 kg. The serratus plane block was performed prior to surgical incision. The block was technically simple compared with thoracic epidural or paravertebral block. All patients were extubated immediately after completion of surgery. Apart from the induction dose of fentanyl (2 µg/kg), no further opioids were required intraoperatively. Postoperative opioid requirements as well as duration of intensive care and hospital stay were lower than recent averages (for the same demographic and procedure) in our hospital. CONCLUSIONS: We propose that the serratus plane block is a simple procedure that provides good perioperative analgesia for infant thoracotomy, potentially facilitating early extubation and a shorter hospital stay.

Ten years of simulation-based training in pediatric anesthesia: The inception, evolution, and dissemination of the Managing Emergencies in Pediatric Anesthesia (MEPA) course.

2016 marked the 10-year anniversary of the inception of the Managing Emergencies in Paediatric Anaesthesia (MEPA) course. This simulation-based program was originally created to allow trainees in pediatric anesthesia to experience operating room emergencies which although infrequent, would be considered key competencies for any practicing anesthetist with responsibility for providing care to children. Since its original manifestation, the course has evolved in content, scope, and worldwide availability, such that it is now available at over 60 locations on five continents. The content has been modified for different learner groups and translated into several languages. This article describes the history, evolution, and dissemination of the MEPA course to share lessons learnt with educators considering the launch of similar initiatives in their field.

Rapid Cycle Deliberate Practice in Medical Education - a Systematic Review.

Rapid Cycle Deliberate Practice (RCDP) is a novel simulation-based education model that is currently attracting interest, implementation, exploration and research in medical education. In RCDP, learners rapidly cycle between deliberate practice and directed feedback within the simulation scenario until mastery is achieved. The objective of this systematic review is to examine the literature and summarize the existing knowledge on RCDP in simulation-based medical education. Fifteen resources met inclusion criteria; they were diverse and heterogeneous, such that we did not perform a quantitative synthesis or meta-analysis but rather a narrative review on RCDP. All resources described RCDP in a similar manner. Common RCDP implementation strategies included: splitting simulation cases into segments, micro debriefing in the form of 'pause, debrief, rewind and try again' and providing progressively more challenging scenarios. Variable outcome measures were used by the studies including qualitative assessments, scoring tools, procedural assessment using checklists or video review, time to active skills and clinical reports. Results were limited and inconsistent. There is an absence of data on retention after RCDP teaching, on RCDP, with learners from specialties other than pediatrics, on RCDP for adult resuscitation scenarios and if RCDP teaching translates into practice change in the clinical realm. We have identified important avenues for future research on RCDP.

Simulation-based assessment of anesthesiology residents' competence: development and implementation of the Canadian National Anesthesiology Simulation Curriculum (CanNASC).

The specialty of anesthesiology will soon adopt the Competence By Design (CBD) approach to residency education developed by the Royal College of Physicians and Surgeons of Canada (RCPSC). A foundational component of CBD is frequent and contextualized assessment of trainees. In 2013, the RCPSC Anesthesiology Specialty Committee assembled a group of simulation educators, representing each of the 17 Canadian anesthesiology residency programs, to form the Canadian National Anesthesiology Simulation Curriculum (CanNASC) Task Force. The goals were to develop, implement, and evaluate a set of consensus-driven standardized mannequin-based simulation scenarios that every trainee must complete satisfactorily prior to completion of anesthesiology residency and certification. Curriculum development followed Kern's principles and was accomplished via monthly teleconferences and annual face-to-face meetings. The development and implementation processes included the following key elements: 1) Curriculum needs assessment: 368 of 958 invitees (38.4%) responded to a national survey resulting in 64 suggested scenario topics. Use of a modified Delphi technique resulted in seven important and technically feasible scenarios. 2) Scenario development: All scenarios have learning objectives from the National Curriculum for Canadian Anesthesiology Residency. Standardized scenario templates were created, and the content was refined and piloted. 3) Assessment: A validated Global Rating Scale (GRS) is the primary assessment tool, informed by using scenario-specific checklists (created via a modified Delphi technique) and the Anesthesia Non-Technical Skills GRS. 4) Implementation: Standardized implementation guidelines, pre-brief/debrief documents, and rater training videos, guide, and commentary were generated. National implementation of the scenarios and program evaluation is currently underway. It is highly feasible to achieve specialty-based consensus on the elements of a national simulation-based curriculum. Our process could be adapted by any specialty interested in implementing a simulation-based curriculum incorporating competency-based assessment on a national scale.

Learning crisis resource management: Practicing versus an observational role in simulation training - a randomized controlled trial.

AIM: Simulation training has been shown to be an effective way to teach crisis resource management (CRM) skills. Deliberate practice theory states that learners need to actively practice so that learning is effective. However, many residency programs have limited opportunities for learners to be "active" participants in simulation exercises. This study compares the effectiveness of learning CRM skills when being an active participant versus being an observer participant in simulation followed by a debriefing. METHODS: Participants were randomized to two groups: active or observer. Active participants managed a simulated crisis scenario (pre-test) while paired observer participants viewed the scenario via video transmission. Then, a trained instructor debriefed participants on CRM principles. On the same day, each participant individually managed another simulated crisis scenario (post-test) and completed a post-test questionnaire. Two independent, blinded raters evaluated all videos using the Ottawa Global Rating Scale (GRS). RESULTS: Thirty-nine residents were included in the analysis. Normally distributed data were analyzed using paired and unpaired t-tests. Inter-rater reliability was 0.64. Active participants significantly improved from pre-test to post-test (P=0.015). There was no significant difference between the post-test performance of active participants compared to observer participants (P=0.12). CONCLUSION: We found that learning CRM principles was not superior when learners were active participants compared to being observers followed by debriefing. These findings challenge the deliberate practice theory claiming that learning requires active practice. Assigning residents as observers in simulation training and involving them in debriefing is still beneficial.

The construction and implementation of a novel postburn pruritus scale for infants and children aged five years or less: introducing the Toronto Pediatric Itch Scale.

The authors' objectives were to design, refine, validate and implement a behavior-anchored postburn pruritus scale for children aged 5 years or less. We engaged a range of professionals involved in the care of children with burns. We used Q-methodology in interprofessional team exercises to identify and stratify itch behaviors into categories of increasing severity, and then iteratively refined these into a draft scale. We used a range of quantitative and qualitative techniques to assess the utility, feasibility, and validity of the scale and refined it accordingly. During the implementation phase we collected some preliminary reliability data. We generated a 4-point scale of itch severity with simple descriptors of each score. We also designed a separate guidance note and example behaviors that could be used to orientate new users without the need for rater training. End-user interviews revealed high levels of feasibility and content validity. The reliability data showed moderate inter-observer agreement, with a Cohen's kappa of 0.52 (P < .001). We have developed and implemented a behavioral post-burn pruritus scale for use in children aged less than 5 years and have demonstrated its utility, feasibility, validity, and reliability. The development of a validated symptom scoring scales will allow for the conduct of high-quality quantitative clinical trials and the subsequent implementation of evidence-based management protocols.

A description of communication patterns during CPR in ICU.

BACKGROUND: Deficiencies in communication in health care are a common source of medical error. Preferred communication patterns are a component of resuscitation teaching. We audio-recorded resuscitations in a mixed paediatric medical and surgical ICU to describe communication. METHODS: In the intensive care unit, resuscitation events were prospectively audio-recorded by two trained observers (using handheld recorders). Recordings were transcribed and anonymised within 24h. We grouped utterances regarding the same subject matter from beginning (irrespective of response) as a communication epoch. For each epoch, we describe the initiator, audience and content of message. Teamwork behaviours were described using Anesthesia Nontechnical Skills framework (ANTS), a behavioural marker system for crisis-resource management. RESULTS: Consent rates from staff were 139/140 (99%) and parents were 67/92 (73%). We analysed 36min 57s of audio dialogue from 4 cardiac arrest events in 363h of prospective screening. There were 180 communication epochs (1 every 12s): 100 (56%) from the team-leader and 80 (44%) from non-team-leader(s). Team-leader epochs were to give or confirm orders or assert authority (61%), clarify patient history (14%) and provide clinical updates (25%). Non-team-leader epochs were more often directed to the team (65%) than the team-leader (35%). Audio-recordings provided information for 80% of the ANTS component elements with scores of 2-4. CONCLUSION: Communication epochs were frequent, most from the team-leader. We identified an 'outer loop' of communication between team members not including the team-leader, responsible for 44% of all communication events. We discuss difficulties in this research methodology. Future work includes exploring the process of the 'outer loop' by resuscitation team members to evaluate the optimal balance between single leader and team suggestions, the content of the outer loop discussions and in-event communication strategies to improve outcomes.

The Managing Emergencies in Paediatric Anaesthesia global rating scale is a reliable tool for simulation-based assessment in pediatric anesthesia crisis management.

INTRODUCTION: The use of simulation-based assessments for high-stakes physician examinations remains controversial. The Managing Emergencies in Paediatric Anaesthesia course uses simulation to teach evidence-based management of anesthesia crises to trainee anesthetists in the United Kingdom (UK) and Canada. In this study, we investigated the feasibility and reliability of custom-designed scenario-specific performance checklists and a global rating scale (GRS) assessing readiness for independent practice. METHODS: After research ethics board approval, subjects were videoed managing simulated pediatric anesthesia crises in a single Canadian teaching hospital. Each subject was randomized to two of six different scenarios. All 60 scenarios were subsequently rated by four blinded raters (two in the UK, two in Canada) using the checklists and GRS. The actual and predicted reliability of the tools was calculated for different numbers of raters using the intraclass correlation coefficient (ICC) and the Spearman-Brown prophecy formula. RESULTS: Average measures ICCs ranged from 'substantial' to 'near perfect' (P ≤ 0.001). The reliability of the checklists and the GRS was similar. Single measures ICCs showed more variability than average measures ICC. At least two raters would be required to achieve acceptable reliability. CONCLUSIONS: We have established the reliability of a GRS to assess the management of simulated crisis scenarios in pediatric anesthesia, and this tool is feasible within the setting of a research study. The global rating scale allows raters to make a judgement regarding a participant's readiness for independent practice. These tools may be used in the future research examining simulation-based assessment.