Twelve tips for developing simulation-based mastery learning clinical skills checklists.

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

Outcomes of Children Discharged Prior to Absolute Neutrophil Count Recovery After Admission for Febrile Neutropenia.

Febrile neutropenia (FN) management in pediatric oncology patients traditionally necessitates inpatient admission until evidence of bone marrow recovery. Discharge before count recovery may be a way to safely reduce the length of hospitalizations for select patients. A chart review was conducted of patients admitted for FN at one tertiary care children's hospital, where the standard is to discharge well-appearing patients after 48 hours of negative cultures if afebrile for at least 24 hours, irrespective of absolute neutrophil count (ANC). Patients with ANC <500 at discharge were identified as early discharges, and data were collected with respect to rates of readmission and infectious complications in this cohort. Among 1230 FN encounters, 765 (62%) were early discharges. 122 patients (15.9%) were readmitted within 7 days. Patients with acute myeloid leukemia and ANC <100 at discharge were more likely to be readmitted. Of the early discharges, only 10 (1.31%) were readmitted with positive blood cultures and 5 (0.7%) were admitted to the pediatric intensive care unit within 24 hours of readmission. Routine discharge before ANC recovery allows for short hospital stays with low rates of readmission, infectious complications, and critical illness for pediatric oncology patients. This safe and beneficial policy should be considered at other institutions.

Development and Implementation of a Novel Curriculum for Emergent Management of Adults with Congenital Heart Disease.

The number of adults with congenital heart disease is rapidly increasing, resulting in more emergency care needs of this unique population. Concomitantly, the number of physicians trained in adult congenital heart disease (ACHD) care is insufficient, leading to physicians with limited experience assuming primary responsibility for the management of acute illness. We developed a simulation-based curriculum consisting of three cases and linked assessment instruments for fellows in multiple training programs to enhance their experience in this growing field. A 40-min asynchronous didactic presentation on ACHD emergencies was provided between pretests and posttests. Each participant was given checklist, global, and timeliness scores, and a second rater scored a subset to assess inter-rater reliability. Twenty-two participants across multiple disciplines completed the study. Our results demonstrate a significant and meaningful improvement in checklist scores, as well as a significant improvement in the secondary measures of global and efficiency performance from the first simulation to the second. Comfort levels for trainees improved significantly on post-test surveys. Inter-rater reliability was greater than 0.6 for all assessments. In conclusion, our novel simulation-based educational curriculum improved trainee performance in managing emergencies in adults with congenital heart disease, and we provide validity evidence for use of our checklist in training fellows for formative feedback.

Expert Consensus Guidelines for Assessing Students on the Social Determinants of Health.

PHENOMENON: Assessment and evaluation guidelines inform programmatic changes necessary for educational effectiveness. Presently, no widely accepted guidelines exist for educators to assess learners and evaluate programs regarding social determinants of health (SDOH) during physician and physician assistant (PA) education. We sought to garner expert consensus about effective SDOH learner assessment and program evaluation, so as to make recommendations for best practices related to SDOH education. APPROACH: We used a Delphi approach to conduct our study (September 2019 to December 2020). To administer our Delphi survey, we followed a three-step process: 1) literature review, 2) focus groups and semi-structured interviews, 3) question development and refinement. The final survey contained 72 items that addressed SDOH content areas, assessment methods, assessors, assessment integration, and program evaluation. Survey participants included 14 SDOH experts at US medical schools and PA programs. The survey was circulated for three rounds seeking consensus, and when respondents reached consensus on a particular question, that question was removed from subsequent rounds. FINDINGS: The geographically diverse sample of experts reached consensus on many aspects of SDOH assessment and evaluation. The experts selected three important areas to assess learners' knowledge, skills, and attitudes about SDOH. They identified assessment methods that were "essential", "useful, but not essential", and "not necessary." The essential assessment methods are performance rating scales for knowledge and attitudes and skill-based assessments. They favored faculty and patients as assessors, as well as learner self-assessment, over assessments conducted by other health professionals. Questions about separation versus incorporation of SDOH assessment with other educational assessment did not yield consensus opinion. The experts reached consensus on priority outcome measures to evaluate a school's SDOH program which included student attitudes toward SDOH, Competence-Based Assessment Scales, and the percentage of graduates involved in health equity initiatives. INSIGHTS: Based on the Delphi survey results, we make five recommendations that medical and PA educators can apply now when designing learner assessments and evaluating SDOH programming. These recommendations include what should be assessed, using what methods, who should do the assessments, and how they should be incorporated into the curriculum. This expert consensus should guide future development of an assessment and evaluation toolkit to optimize SDOH education and clinical practice.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2022.2045490 .

Assessment and Evaluation in Social Determinants of Health Education: a National Survey of US Medical Schools and Physician Assistant Programs.

BACKGROUND: Social determinants of health (SDOH) curricular content in medical schools and physician assistant programs are increasing. However, there is little understanding of current practice in SDOH learner assessment and program evaluation, or what the best practices are. OBJECTIVE: Our study aim was to describe the current landscape of assessment and evaluation at US medical schools and physician assistant programs as a first step in developing best practices in SDOH education. DESIGN: We conducted a national survey of SDOH educators from July to December 2020. The 55-item online survey covered learner assessment methods, program evaluation, faculty training, and barriers to effective assessment and evaluation. Results were analyzed using descriptive statistics. PARTICIPANTS: One hundred six SDOH educators representing 26% of medical schools and 23% of PA programs in the USA completed the survey. KEY RESULTS: Most programs reported using a variety of SDOH learner assessment methods. Faculty and self were the most common assessors of learners' SDOH knowledge, attitudes, and skills. Common barriers to effective learner assessment were lack of agreement on "SDOH competency" and lack of faculty training in assessment. Programs reported using evaluation results to refine curricular content, identify the need for new content, and improve assessment strategies. CONCLUSIONS: We identified a heterogeneity of SDOH assessment and evaluation practices among programs, as well as gaps and barriers in their educational practices. Specific guidance from accrediting bodies and professional organizations and agreement on SDOH competency as well as providing faculty with time, resources, and training will improve assessment and evaluation practice and ensure SDOH education is effective for students, patients, and communities.

Varying Estimates of Sepsis among Adults Presenting to US Emergency Departments: Estimates from a National Dataset from 2002-2018.

BACKGROUND: A variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria. METHODS: We performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection. RESULTS: Age-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time. CONCLUSION: The explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.

Outcomes and Factors Associated With Prehospital Treatment of Pediatric Anaphylaxis.

OBJECTIVE: Anaphylaxis is a potentially life-threatening reaction requiring prompt treatment with intramuscular epinephrine (EPI). We sought to describe presenting features of pediatric anaphylaxis and compare patient characteristics and outcomes of children treated with prehospital EPI with those untreated. METHODS: We abstracted data from emergency department (ED) records for children meeting the National Institute of Allergy & Infectious Disease criteria for anaphylaxis (2015-2017) in one tertiary care children's hospital. We analyzed associations between patient characteristics and outcomes and receipt of prehospital EPI using descriptive statistics and multivariate logistic regression. RESULTS: Of 414 children presenting with anaphylaxis, 39.4% received IM EPI and 62.1% received antihistamines before hospital arrival. Children with Medicaid received pre-emergency department EPI less frequently than did children with private insurance (24.5% vs 43.8%, P = 0.001). Factors positively associated with prehospital EPI administration were history of food allergy (odds ratio [OR], 4.4 [95% confidence interval {CI}, 2.4-8.2]) or arrival by emergency medical services (OR, 8.0 [95% CI, 4.2-15.0]). Medicaid insurance was associated with decreased odds of prehospital EPI (OR, 0.33 [95% CI, 0.16-0.66]) and prehospital H1-antihistamine use (OR, 0.30 [95% CI, 0.17-0.56]). Prehospital EPI treatment was also associated with decreased rates of observation (37% vs 63%), inpatient admission (38% vs 62%), and intensive care unit admission (20% vs 80%) compared with no pretreatment (P = 0.03). CONCLUSIONS: Prehospital treatment with EPI remains low, and barriers to optimal treatment are more pronounced in children with public insurance. Prehospital treatment with EPI was associated with decreased morbidity including hospitalization and intensive care unit admission.

Clinical characteristics and predictors of mortality in African-Americans with COVID-19 from an inner-city community teaching hospital in New York.

There is limited data on the clinical presentation and predictors of mortality in the African-American (AA) patients hospitalized with coronavirus disease 2019 (COVID-19) despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID-19 infection. In this retrospective cohort review, we included all AA patients with confirmed COVID-19 infection admitted to an inner-city teaching community hospital in New York city. Demographics, clinical presentation, baseline co-morbidities, and laboratory data were compared between survivors and non-survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Of the 408 (median age, 67 years) patients included, 276 (66.65%, median age 63 years) survived while 132 (33.35%, median age 71 years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (odds ratio [OR], 1.06; confidence interval [CI], 1.04-1.08; P < .001), body mass index (OR, 1.07; CI, 1.04-1.11; P < .001), elevated serum ferritin (OR, 1.99; CI, 1.08-3.66; P < .02), C-reactive protein (OR, 2.42; CI, 1.36-4.33; P < .01), and D-dimers (OR, 3.79; CI, 2.21-6.50; P < .001) at the time of presentation were identified as the independent predictors of mortality. Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among AAs hospitalized with COVID-19 infection. Advanced age, higher body mass index, elevated serum ferritin, C-reactive protein, and D-dimers are independent predictors of mortality among hospitalized AAs with COVID-19 infection.

Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Tasks.

OBJECTIVES: Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. METHODS: This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. RESULTS: There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. CONCLUSIONS: Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context.

Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance: A Controlled Trial.

OBJECTIVES: This study aimed to determine whether personal protective equipment (PPE) results in deterioration in chest compression (CC) quality and greater fatigue for administering health care providers (HCPs). METHODS: In this multicenter study, HCPs completed 2 sessions. In session 1 (baseline), HCPs wore normal attire; in session 2, HCPs donned full PPE. During each session, they performed 5 minutes of uninterrupted CCs on a child manikin. Chest compression rate, depth, and release velocity were reported in ten 30-second epochs. Change in CC parameters and self-reported fatigue were measured between the start and 2- and 5-minute epochs. RESULTS: We enrolled 108 HCPs (prehospital and in-hospital providers). The median CC rate did not change significantly between epochs 1 and 10 during baseline sessions. Median CC depth and release velocity decreased for 5 minutes with PPE. There were no significant differences in CC parameters between baseline and PPE sessions in any provider group. Median fatigue scores during baseline sessions were 2 (at start), 4 (at 2 minutes), and 6 (at 5 minutes). There was a significantly higher median fatigue score between 0 and 5 minutes in both study sessions and in all groups. Fatigue scores were significantly higher for providers wearing PPE compared with baseline specifically among prehospital providers. CONCLUSIONS: During a clinically appropriate 2-minute period, neither CC quality nor self-reported fatigue worsened to a significant degree in providers wearing PPE. Our data suggest that Pediatric Basic Life Support recommendations for CC providers to switch every 2 minutes need not be altered with PPE use.

Teaching the Social Determinants of Health in Undergraduate Medical Education: a Scoping Review.

BACKGROUND: To provide optimal care, medical students should understand that the social determinants of health (SDH) impact their patients' well-being. Those charged with teaching SDH to future physicians, however, face a paucity of curricular guidance. OBJECTIVE: This review's objective is to map key characteristics from publications about teaching SDH to students in undergraduate medical education (UME). METHODS: In 2016, the authors searched PubMed, Embase, Web of Science, the Cochrane and ERIC databases, bibliographies, and MedEdPORTAL for articles published between January 2010 and November 2016. Four reviewers screened articles for eligibility then extracted and analyzed data descriptively. Scoping review methodology was used to map key concepts and curricular logistics as well as educator and student characteristics. RESULTS: The authors screened 3571 unique articles of which 22 were included in the final review. Many articles focused on community engagement (15). Experiential learning was a common instructional strategy (17) and typically took the form of community or clinic-based learning. Nearly half (10) of the manuscripts described school-wide curricula, of which only three spanned a full year. The majority of assessment was self-reported (20) and often related to affective change. Few studies objectively assessed learner outcomes (2). CONCLUSIONS: The abundance of initial articles screened highlights the growing interest in SDH in medical education. The small number of selected articles with sufficient detail for abstraction demonstrates limited SDH curricular dissemination. A lack of accepted tools or practices that limit development of robust learner or program evaluation was noted. Future research should focus on identifying and evaluating effective instructional and assessment methodologies to address this gap, exploring additional innovative teaching frameworks, and examining the specific contexts and characteristics of marginalized and underserved populations and their coverage in medical education.

A survey comparison of educational interventions for teaching pneumatic otoscopy to medical students.

BACKGROUND: Though pneumatic otoscopy improves accurate diagnosis of ear disease, trainees lack proficiency. We evaluated the effect of three different training techniques on medical students' subsequent reported use of basic and pneumatic otoscopy in patient encounters. METHODS: Pediatric clerkship students participated in an ear exam workshop with randomization to one of three educational interventions: task trainer (Life/form®, Fort Atkinson WI), instructional video, or peer practice. Each student received an insufflator bulb and logbook to record otoscopic exams and completed an 18-item anonymous survey at clerkship conclusion. RESULTS: 115 of 150 students (77%) completed the survey. There was no significant difference in number of basic or pneumatic otoscopic exams performed based on method of training. Most students (68-72%) felt more likely to perform pneumatic otoscopy after training. Though the majority of students performed basic otoscopy on patients when an ear exam was indicated, they used pneumatic otoscopy less than 10% of the time. Students reported significant barriers to otoscopy: time, access to equipment, cerumen impaction, patient hold, and anxiety. Student comments described a culture where insufflation was neither practiced nor valued by supervising physicians. CONCLUSION: Training in pneumatic otoscopy can increase student comfort, but barriers exist to using the skill in clinical practice.

Using the METRICS model for defining routes to scholarship in healthcare simulation.

INTRODUCTION: In this paper, we explored the utility and value of the METRICS model for modeling scholarship in healthcare simulation by: (1) describing the distribution of articles in four healthcare simulation journals across the seven areas of METRICS scholarship; and (2) appraising patterns of scholarship expressed in three programs of simulation scholarship and reflecting on how these patterns potentially influence the pursuit of future scholarly activities. METHODS: Two raters reviewed abstracts of papers published between January 2015 and August 2017 in four healthcare simulation journals and coded them using METRICS. Descriptive statistics were calculated for scholarship type and distribution across journals. Twenty-eight articles from three scholars were reviewed, with patterns of scholarship within articles mapped to METRICS. Descriptive synthesis was constructed through discussion between two reviewers. RESULTS: A total of 432 articles from four journals were reviewed. The three most commonly published areas of scholarship were: 32.2% (139/432) evaluation, 18.8% (81/432) innovation, and 15.3% (66/432) conceptual. The METRICS model was able to represent different kinds of scholarship expressed in all of the papers reviewed and across programs of research. Reflecting on patterns of scholarship within their scholarly programs was helpful for research in planning future directions. CONCLUSIONS: The METRICS model for scholarship can describe a wide range of patterns of simulation scholarship within individual articles, programs of research, or across journals.

Causes for Pauses During Simulated Pediatric Cardiac Arrest.

OBJECTIVES: Pauses in cardiopulmonary resuscitation negatively impact clinical outcomes; however, little is known about the contributing factors. The objective of this study is to determine the frequency, duration, and causes for pauses during cardiac arrest. DESIGN: This is a secondary analysis of video data collected from a prospective multicenter trial. Twenty-six simulated pediatric cardiac arrest scenarios each lasting 12 minutes in duration were analyzed by two independent reviewers to document events surrounding each pause in chest compressions. SETTING: Ten children's hospitals across Canada, the United, and the United Kingdom. SUBJECTS: Resuscitation teams composed of three healthcare providers trained in cardiopulmonary resuscitation. INTERVENTIONS: A simulated pediatric cardiac arrest case in a 5 year old. MEASUREMENTS AND MAIN RESULTS: The frequency, duration, and associated factors for each pause were recorded. Communication was rated using a four-point scale reflecting the team's shared mental model. Two hundred fifty-six pauses were reviewed with a median of 10 pauses per scenario (interquartile range, 7-12). Median pause duration was 5 seconds (interquartile range, 2-9 s), with 91% chest compression fraction per scenario (interquartile range, 88-94%). Only one task occurred during most pauses (66%). The most common tasks were a change of chest compressors (25%), performing pulse check (24%), and performing rhythm check (15%). Forty-nine (19%) of the pauses lasted greater than 10 seconds and were associated with shock delivery (p < 0.001), performing rhythm check (p < 0.001), and performing pulse check (p < 0.001). When a shared mental model was rated high, pauses were significantly shorter (mean difference, 4.2 s; 95% CI, 1.6-6.8 s; p = 0.002). CONCLUSIONS: Pauses in cardiopulmonary resuscitation occurred frequently during simulated pediatric cardiac arrest, with variable duration and underlying causes. A large percentage of pauses were greater than 10 seconds and occurred more frequently than the recommended 2-minute interval. Future efforts should focus on improving team coordination to minimize pause frequency and duration.

Workload of Team Leaders and Team Members During a Simulated Sepsis Scenario.

OBJECTIVES: Crisis resource management principles dictate appropriate distribution of mental and/or physical workload so as not to overwhelm any one team member. Workload during pediatric emergencies is not well studied. The National Aeronautics and Space Administration-Task Load Index is a multidimensional tool designed to assess workload validated in multiple settings. Low workload is defined as less than 40, moderate 40-60, and greater than 60 signify high workloads. Our hypothesis is that workload among both team leaders and team members is moderate to high during a simulated pediatric sepsis scenario and that team leaders would have a higher workload than team members. DESIGN: Multicenter observational study. SETTING: Nine pediatric simulation centers (five United States, three Canada, and one United Kingdom). PATIENTS: Team leaders and team members during a 12-minute pediatric sepsis scenario. INTERVENTIONS: National Aeronautics and Space Administration-Task Load Index. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-seven teams were recruited from nine sites. One hundred twenty-seven team leaders and 253 team members completed the National Aeronautics and Space Administration-Task Load Index. Team leader had significantly higher overall workload than team member (51 ± 11 vs 44 ± 13; p < 0.01). Team leader had higher workloads in all subcategories except in performance where the values were equal and in physical demand where team members were higher than team leaders (29 ± 22 vs 18 ± 16; p < 0.01). The highest category for each group was mental 73 ± 13 for team leader and 60 ± 20 for team member. For team leader, two categories, mental (73 ± 17) and effort (66 ± 16), were high workload, most domains for team member were moderate workload levels. CONCLUSIONS: Team leader and team member are under moderate workloads during a pediatric sepsis scenario with team leader under high workloads (> 60) in the mental demand and effort subscales. Team leader average significantly higher workloads. Consideration of decreasing team leader responsibilities may improve team workload distribution.

Development and Evaluation of a Learning Intervention Targeting First-Year Resident Defibrillation Skills.

OBJECTIVES: The aim of the study was to evaluate an educational intervention targeting the acquisition and retention of critical core skills of defibrillation in first-year pediatric residents using simulation-based training and deliberate practice. METHODS: From January 2011 to April 2012, a total of 23 first-year pediatric residents participated in a pretest-posttest study. An initial survey evaluated previous experience, training, and comfort. The scoring tool was designed and validated using a standard setting procedure and 60% was determined to be the minimum passing score. The 1-hour educational intervention included a brief video describing the defibrillator, 10 to 15 minutes of hands-on time with the defibrillator, and 30 minutes of simulation-based scenarios using deliberate practice with real-time feedback. RESULTS: The number of subjects who achieved competency in defibrillation skills increased from 8 to 16 of 23 (35% vs 70%, P < 0.05), pretest versus posttest, with the posttest occurring 4 months after the intervention. There was a significant improvement in checklist score (53% vs 68%, P < 0.05) and time to defibrillation (282-189 s, P < 0.05). For those who initiated chest compressions, there was a nonsignificant improvement in time to compressions (50 vs 33 s, P = 0.08). Previous Pediatric Advanced Life Support training was not associated with performance on pretest or posttest. CONCLUSIONS: This brief educational intervention was shown to be effective 4 months after instruction in achieving and retaining competency of defibrillation skills by first-year pediatric residents. In the process, we uncovered educational gaps in cardiopulmonary resuscitation and other resuscitation skills that need to be addressed in future educational interventions and training.

The Past, Present, and Future of Simulation-based Education for Pediatric Emergency Medicine.

The pediatric emergency medicine (PEM) environment is well suited for simulation-based activities, be they educational interventions for PEM learners, evaluations of the interface between health providers and the environment that they work in, or research investigations using simulation as a tool to answer specific clinical questions. As such, PEM has been among the leaders in the integration of this modality for clinical training. Traditionally, simulation has been used extensively for the dissemination of clinical training in the areas of clinical knowledge and its application, and the clinical, technical, and teamwork skills involved in PEM care. Increasingly, simulation is being used in novel applications, including breaking bad news, disclosure of error, family-centered care, quality and patient safety education, and system-level integration. The future will look to further identify, measure, and inform the integration of simulation with new and innovative adjuncts in the clinical environment, as well as to determine the optimal timing and use of simulation-based education to enhance the quality of care delivered to patients by the interprofessional and multidisciplinary team.

Upper gastrointestinal fluoroscopic simulator for neonates with bilious emesis.

Prompt diagnosis of malrotation and midgut volvulus in infants with bilious emesis is critical. However because of the limited frequency of pediatric upper gastrointestinal (UGI) fluoroscopic procedures in neonates, many diagnostic radiology residents complete their training never having seen or performed a UGI on a baby for evaluation of malrotation and midgut volvulus. A UGI simulation model for infants with bilious emesis was created to supplement the hands-on fluoroscopic experience of residents in training. We are now studying the addition of simulated UGI studies to our pediatric radiology curriculum.