Diagnostic Value of Lactate Dehydrogenase and Uric Acid as Screening Tools for Malignancies in Children.

OBJECTIVE: The aim of this study was to determine the diagnostic value of lactate dehydrogenase (LDH) and uric acid (UA) in children undergoing evaluation for possible malignancies. METHODS: This was a retrospective chart review of patients aged 0 to 18 years presenting to an urban, tertiary care, pediatric hospital between July 1, 2011, and July 1, 2016. Patients were included if they had an LDH and/or UA level drawn, and they were excluded if they had a known cancer diagnosis. Sensitivity, specificity, and receiver operating characteristic curves were calculated for each biomarker. RESULTS: Six hundred five subjects were included in this study; 579 and 384 subjects had LDH and UA levels drawn, respectively; 15.7% had a final diagnosis of malignancy (49 leukemia, 46 nonleukemia). CONCLUSION: The specificities of both biomarkers for all types of malignancies were lower than their respective sensitivities. Comparing leukemic versus nonleukemic malignancies, the areas under the curve were 0.848 and 0.719, respectively, for LDH and 0.681 and 0.555, respectively, for UA.

Clinical Characteristics of Acute Hematogenous Osteomyelitis With and Without Subperiosteal Abscesses in the Acute Care Setting.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a common pediatric disease that can progress to involve nearby structures leading to complications including subperiosteal abscesses (SPAs). Those with SPAs, in particular, often require surgical intervention for complete treatment. Staphylococcus aureus remains one of the most common causes of AHO. With the emergence of community-associated methicillin-resistant Ataphylococcus aureus and its propensity to form abscesses, there has been an observed increased frequency of AHO with SPAs in children. Although magnetic resonance imaging (MRI) remains the gold standard of imaging for AHO, it is not readily available on a 24/7 basis and often necessitates procedural sedation in children. Delay in MRI and surgical intervention in patients with SPAs may lead to increased complications. The goal of this study is to identify, using clinical features easily obtained in the acute care setting, patients at high risk for AHO with SPAs who may benefit from emergent MRI and/or surgical intervention. DESIGN/METHODS: A retrospective chart review of patients aged birth to younger than 18 years diagnosed with AHO, who presented to a tertiary pediatric hospital from June 10, 2012, to November 1, 2017, were evaluated. Demographic, clinical, laboratory, and imaging data were collected. Patients were divided into 2 groups: AHO alone and AHO with SPAs. RESULTS: A final cohort of 110 subjects were included and analyzed. Of these, 73 (66%) were identified as having AHO alone and 37 (33.6%) as having AHO with SPAs. Patients had a higher risk of AHO with SPAs if they had a history of fever, decreased range of motion, edema, or elevated laboratory studies including white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein. C-reactive protein was shown to have the highest correlation of AHO with SPAs, with an optimal cut point of 10.3 mg/dL, yielding a sensitivity of 67.7% and specificity of 77.6%. Patients with AHO with SPAs were at higher risk of having a positive blood culture for methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Clinicians in acute care settings should have a high index of suspicion of AHO with SPAs in children with history of fever, decreased range of motion, or elevated laboratory values (white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein). In particular, those with a significantly elevated CRP are at a higher risk for having AHO with SPAs in comparison with an uncomplicated AHO. However, with the significant overlap in historical and clinical variables in the initial presentations of children with AHO with and without SPAs, the clinical urgency in obtaining a magnetic resonance imaging must continue to be individualized based on overall clinical suspicion and availability of resources.

Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain.

OBJECTIVES: Previous studies have not evaluated the utility of obtaining chest radiographs (CXR) in patients with acute asthma exacerbation reporting chest pain. The aims of this study were to evaluate the symptom of chest pain as a predictor for clinicians obtaining a CXR in these patients and to evaluate chest pain as a predictor of a positive CXR finding. METHODS: This was a retrospective chart review of patients, ages 2 to 18 years, presenting for acute asthma exacerbation to the emergency department from August 1, 2014, to March 31, 2016. Data collected included demographics, clinical data, provider type, and CXR results. Chest radiographs were classified as positive if they showed evidence of pneumonia, pneumothorax, or pneumomediastinum. Multivariate logistic regression models were developed with dependent variables of "obtaining a CXR" and "a positive CXR finding." RESULTS: Seven hundred ninety-three subjects were included in the study. Two hundred thirty-one (29.1%) reported chest pain. Chest radiographs were obtained in 184 patients (23.2%). Of those, 74 patients (40.2%) had chest pain and 21 (11.4%) had a positive CXR. Providers were more likely to obtain CXRs in patients who reported chest pain (odds ratio = 2.2 [95% confidence interval = 1.5-3.2]). Patients reporting chest pain were more likely to have a positive CXR although this difference was not statistically significant (odds ratio = 2.0 [95% confidence interval = 0.7-5.6]). CONCLUSIONS: Providers are more likely to obtain CXRs in asthmatic patients complaining of chest pain; however, these CXRs infrequently yield positive findings. This further supports limiting the use of chest radiography in patients with acute asthma exacerbation.

Repeat Intravenous Ketamine Dosing in Children Undergoing Emergency Department Procedural Sedation.

BACKGROUND: Patients undergoing procedural sedation with intravenous ketamine often receive repeat doses to maintain dissociation; however, data between doses are lacking. OBJECTIVES: The purpose of this study was to characterize the frequency, time interval, and dosages of ketamine received by children undergoing procedural sedation and to explore the effects of age and body mass index on these parameters. METHODS: This was a retrospective study of patients 1 to 18 years of age undergoing procedural sedation with intravenous ketamine in a pediatric emergency department between October 2016 and June 2017. Total repeat ketamine dosages were standardized to a 1-h sedation. RESULTS: Four hundred nineteen patients were included in the analysis. The median sedation time was 33.0 minutes (interquartile range [IQR] 25.0-45.0). Three hundred sixty-three patients (86.6%) received at least 1 repeat ketamine dose. The median time between doses was 7.0 minutes (IQR 5.0-12.0). Children <6 years of age, compared with older children, received higher hourly doses of ketamine in mg/kg/h (2.8 [IQR 1.8-3.9] vs. 1.8 [IQR 1.2-2.6], pc < 0.01). Children <3 years of age, compared with older children, received the highest hourly dose of ketamine in mg/kg/h (3.7 [IQR 2.3-5.0] vs. 1.9 [IQR 1.4-2.8], pc < 0.01). Ketamine repeat and hourly dosing does not appear to be significantly different in children of differing body mass index classes. CONCLUSIONS: Patients undergoing ketamine sedation often receive repeat doses to maintain dissociation. Patients <3 years of age received the highest total repeat ketamine dosages.

Critical Care Interventions for Asthmatic Patients Admitted From the Emergency Department to the Pediatric Intensive Care Unit.

OBJECTIVES: The aim of this study was to assess the frequency and predictors of critical interventions in asthmatic patients admitted to the pediatric intensive care unit (PICU) at a tertiary-care pediatric hospital. METHODS: We conducted a retrospective chart review of patients admitted from our emergency department (ED) to the PICU for treatment of status asthmaticus between January 1, 2008, and March 31, 2013. Patients with concomitant medical conditions and those who received a critical intervention, other than continuously aerosolized albuterol, in the ED before admission were excluded. Data collected included patient demographics, clinical characteristics including clinical asthma scores (CASs), hospital course, and adverse events. RESULTS: A total of 384 patients were included in the analyses (mean age, 8.2 ± 4.5 years). Thirty-four patients (8.9%) received at least 1 critical intervention. No patients were intubated, had central venous catheter placement, and developed circulatory collapse or pneumothoraxes. Independent predictors associated with an increased likelihood of receiving a critical intervention included age above 8 years (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.9-9.4), previous PICU admission (OR, 3.2; 95% CI, 1.5-6.6), altered mental status on ED arrival (OR, 4.5; 95% CI, 1.5-13.4), CAS on ED arrival of 5 or greater (OR, 3.4; 95% CI, 1.3-9.1), and CAS on PICU admission of 5 or greater (OR, 4.3; 95% CI, 1.8-10.2). CONCLUSIONS: Patients admitted to the PICU for status asthmaticus infrequently require critical interventions if they have not been initiated in the ED. Patients with a CAS of less than 5 may be safely managed with continuously aerosolized albuterol on non-critical care units with low risk for clinical deterioration.

Can Residents Assess Other Providers' Infant Lumbar Puncture Skills?: Validity Evidence for a Global Rating Scale and Subcomponent Skills Checklist.

OBJECTIVES: The aims of this study were to provide validity evidence for infant lumbar puncture (ILP) checklist and global rating scale (GRS) instruments when used by residents to assess simulated ILP performances and to compare these metrics to previously obtained attending rater data. METHODS: In 2009, the International Network for Simulation-based Pediatric Innovation, Research, and Education (INSPIRE) developed checklist and GRS scoring instruments, which were previously validated among attending raters when used to assess simulated ILP performances. Video recordings of 60 subjects performing an LP on an infant simulator were collected; 20 performed by subjects in 3 categories (beginner, intermediate, and expert). Six blinded pediatric residents independently scored each performance (3 via the GRS, 3 via the checklist). Four of the 5 domains of validity evidence were collected: content, response process, internal structure (reliability and discriminant validity), and relations to other variables. RESULTS: Evidence for content and response process validity is presented. When used by residents, the checklist performed similarly to what was found for attending raters demonstrating good internal consistency (Cronbach α = 0.77) and moderate interrater agreement (intraclass correlation coefficient = 0.47). Residents successfully discerned beginners (P < 0.01, effect size = 2.1) but failed to discriminate between expert and intermediate subjects (P = 0.68, effect size = 0.34). Residents, however, gave significantly higher GRS scores than attending raters across all subject groups (P < 0.001). Moderate correlation was found between GRS and total checklist scores (P = 0.49, P < 0.01). CONCLUSIONS: This study provides validity evidence for the checklist instrument when used by pediatric residents to assess ILP performances. Compared with attending raters, residents appeared to over-score subjects on the GRS instrument.

Prevalence of Retinal Hemorrhages in Infants Presenting with Isolated Long Bone Fractures and Evaluation for Abuse.

BACKGROUND: Fractures are a frequent reason for emergency department visits and evaluation for abusive head trauma is an associated concern in infants. Recent guidelines have suggested that retinal examination may not be necessary in the absence of intracranial injury, but there is a lack of empirical evidence in infants < 1 year of age. OBJECTIVE: Our aim was to evaluate the prevalence of retinal hemorrhages in infants with isolated long bone fractures. METHODS: Retrospective chart review of infants < 1 year of age who presented to an urban, tertiary care pediatric hospital between January 2004 and April 2014 with the diagnosis of an acute long bone fracture or retinal hemorrhages. Patients were excluded for head injury, altered mental status, injury mechanism of motor vehicle accident, multiple fractures or injuries outside the fracture area. Patients were identified through trauma registry data and International Classification of Diseases codes. RESULTS: One hundred and forty-six patients had isolated long bone fractures, of which 68 patients did not undergo a retinal examination and 78 patients had dilated eye examinations, with no patients identified as having retinal hemorrhages. There were 46 patients identified with retinal hemorrhages concerning for abuse. No patients with retinal hemorrhages had isolated long bone fractures. CONCLUSIONS: In infants < 1 year of age presenting with isolated long bone fractures, a dilated eye examination to evaluate for retinal hemorrhages is not likely to yield additional information. Our results support recent studies that a subset of children and infants may not require dilated eye examinations in the evaluation of possible abuse.

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting.

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED). METHODS: Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed. RESULTS: A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified. CONCLUSIONS: Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.

A fixed-dose ketamine protocol for adolescent sedations in a pediatric emergency department.

OBJECTIVES: To assess provider and patient satisfaction with a fixed-dose ketamine protocol for procedural sedation of adolescent subjects. We further compared data for normal weight (body mass index [BMI] ≤ 25 kg/m(2)) vs overweight/obese subjects (BMI >25 kg/m(2)). STUDY DESIGN: Prospective, observational cohort study of adolescent patients undergoing procedural sedation in a pediatric emergency department. Adequate sedation was defined as a Ramsay Sedation Score (RSS) ≥ 5. Subjects received an initial 50 mg intravenous ketamine dose followed by 25 mg intravenous doses to maintain an RSS ≥ 5. The sedating physician, procedural physician, and sedating nurse independently rated the sedations on a 100 mm visual analog scale (0 = "very unsatisfied", 100 = "very satisfied"). Subjects and their guardians were contacted 12-24 hours postsedation. RESULTS: Forty-three subjects (26 normal weight, 17 overweight/obese), aged 12-17 years, were enrolled in the study. An RSS ≥ 5 was observed in 35 (81.4%) of the subjects following the initial 50 mg ketamine dose and in the remaining 8 subjects following the first additional 25 mg dose. The median combined provider satisfaction score for the sedations was 92.7 (IQR 83.7-95.0) and was similar for the normal weight and overweight/obese groups (93.1 [IQR 84.6-95.9] vs 89.7 [IQR 83.7-93.5], respectively, P = .27). Subjects and guardians in both groups reported high rates of satisfaction. CONCLUSION: The fixed-dose ketamine protocol resulted in an adequate level of sedation and high provider/patient satisfaction for the majority of patients regardless of weight or BMI status.

Simulation training for pediatric residents on central venous catheter placement: a pilot study.

OBJECTIVE: To assess the effect of simulation training on pediatric residents' acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure. DESIGN: Prospective observational pilot study. SETTING: Single university clinical simulation center. SUBJECTS: Pediatric residents, postgraduate years 1-3. INTERVENTIONS: Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale. MEASUREMENTS AND MAIN RESULTS: Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 83.3% [interquartile range, 70.0-91.7%]), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 79.5 mm [interquartile range, 16.3-91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8-19.0 mm] vs 52.0 mm [interquartile range, 43.5-66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 54.2% [interquartile range, 45.8-80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 35.5 mm [interquartile range, 5.3-77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8-19.0 mm] vs 61.0 mm [interquartile range, 31.5-71.8 mm], p < 0.01). CONCLUSIONS: Simulation training improved pediatric residents' central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Rapid bedside triage does not affect the delivery of pain medication for extremity pain in the pediatric emergency department.

OBJECTIVE: Rapid bedside triage (RBT), rather than traditional waiting room triage (WRT), is becoming a "best practice" in managing emergency department (ED) patient flow, yet little is known about the impact of this process on other aspects of patient care. This study was designed to compare overall adherence to an existing nurse-driven ED pain protocol after changing from a WRT to an RBT process. METHODS: On November 1, 2011, the triage process at our institution changed from a traditional WRT system to an in-department RBT allowing for comparison of the 2 groups. A retrospective chart review assessing compliance with the department's pain protocol was performed on all patients presenting to the ED during October and November 2011, representing the immediate time periods before and after the implementation of the change in triage process. Patients younger than 19 years, with complaint of isolated extremity pain or injury, were included in this analysis. Compliance was defined as patients having a pain score assessed and pain medication given for scores of 4 or more within 30 minutes of arrival. RESULTS: In total, 546 patients were identified for inclusion in the study; 306 received traditional WRT, and 240 received RBT. Compliance with the pain protocol was seen in 54.6% of patients receiving WRT versus 57.5% receiving RBT (P = 0.50). CONCLUSIONS: Changing from a traditional WRT process to an in-department RBT process resulted in no change in the compliance with the existing pain protocol.

Evaluation of a high-dose continuous albuterol protocol for treatment of pediatric asthma in the emergency department.

OBJECTIVES: This study aimed to assess the safety and efficacy of a high-dose continuous nebulized albuterol (CNA) protocol for treatment of asthma in the pediatric emergency department (ED). A secondary objective included a cost-benefit analysis of protocol use. METHODS: In this retrospective chart review, we compared cohorts of patients treated in our ED for acute asthma exacerbation before and after implementation of a CNA protocol. Patients between the ages of 2 and 21 years seen between March 1 and May 31, 2008 (preprotocol, n = 393), and March 1 to May 31, 2009 (postprotocol, n = 373), were included. Safety data included medication-related adverse effects as well as serum potassium and glucose levels. Efficacy data included ED length of stay, disposition, return visits, time to first albuterol treatment, and corticosteroid administration. Cost analysis included the cost of medications and respiratory therapy time. RESULTS: Postprotocol patients more often received CNA (57.9% vs 25.2%, P < 0.01). No significant adverse effects, including tachyarrhythmia and symptomatic hypokalemia, were found in either group. Serum potassium levels were higher in the postprotocol group (3.9 mEq/L [n = 34] vs 3.5 mEq/L [n = 28], P < 0.01). Emergency department stay was longer in the postprotocol group (217.8 minutes vs 187.2 minutes, P < 0.01). Emergency department disposition was similar in both groups. The mean cost per patient was higher in the postprotocol group ($327.21 vs $277.95, P < 0.01). CONCLUSIONS: We found the CNA protocol to be safe. Superior efficacy to a traditional treatment approach was not demonstrated. The mean cost of treatment was higher in the postprotocol group. Further prospective studies should be conducted to confirm the findings of this retrospective, observational study.

Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation?

OBJECTIVES: The objective of this study was to determine if overweight children are more likely than normal-weight children to require ondansetron when undergoing ketamine sedation in a pediatric emergency department. METHODS: Patients between the ages of 2 and 18 years with an American Society of Anesthesiologists classification of I or II who underwent intravenous procedural sedation with ketamine with or without midazolam for uncomplicated forearm fracture reduction in an urban pediatric emergency department during the year 2007 were included. A review of sedation records was conducted for each visit. Data collected included demographics, sedation time, and doses of medications administered. Body mass index (BMI) was calculated using an estimated height for the 50th percentile for age and sex. In 2007, all patients underwent procedural sedation per protocol. Per protocol, patients did not prophylactically receive ondansetron during procedural sedations. RESULTS: During the study period, 141 patients were identified who met inclusion criteria. Of these, 110 had an estimated BMI less than 25 kg/m; 31 had an estimated BMI of 25 kg/m or greater. Ten patients (7.1%) received ondansetron. Patients in the high-BMI group were more likely to have received ondansetron than those in the normal-BMI group (16.1% vs 4.5%, P = 0.04). CONCLUSIONS: Our data suggest that pediatric patients with high BMIs are at greater risk for nausea or emesis during ketamine sedation. Clinicians should consider prophylactic administration of ondansetron to this group of patients before performing ketamine sedation.

Greater saphenous vein location in a pediatric population.

The purpose of this study was to assess the accuracy of a landmark technique for cannulation of the greater saphenous vein (GSV) near the medial malleolus. We performed bedside ultrasound in a convenience sample of 100 children, ages 3 to 16 years, to evaluate the anatomy of the GSV at the ankle. Despite the proposed constancy of the landmark technique regardless of patient age, the GSV location varied significantly with increasing patient age and weight. In children less than 10 years old or weighing less than 40 kg, the traditional landmark rarely predicted the precise location of the GSV.

Validity Evidence for a Serious Game to Assess Performance on Critical Pediatric Emergency Medicine Scenarios.

INTRODUCTION: We developed a first-person serious game, PediatricSim, to teach and assess performances on seven critical pediatric scenarios (anaphylaxis, bronchiolitis, diabetic ketoacidosis, respiratory failure, seizure, septic shock, and supraventricular tachycardia). In the game, players are placed in the role of a code leader and direct patient management by selecting from various assessment and treatment options. The objective of this study was to obtain supportive validity evidence for the PediatricSim game scores. METHODS: Game content was developed by 11 subject matter experts and followed the American Heart Association's 2011 Pediatric Advanced Life Support Provider Manual and other authoritative references. Sixty subjects with three different levels of experience were enrolled to play the game. Before game play, subjects completed a 40-item written pretest of knowledge. Game scores were compared between subject groups using scoring rubrics developed for the scenarios. Validity evidence was established and interpreted according to Messick's framework. RESULTS: Content validity was supported by a game development process that involved expert experience, focused literature review, and pilot testing. Subjects rated the game favorably for engagement, realism, and educational value. Interrater agreement on game scoring was excellent (intraclass correlation coefficient = 0.91, 95% confidence interval = 0.89-0.9). Game scores were higher for attendings followed by residents then medical students (Pc < 0.01) with large effect sizes (1.6-4.4) for each comparison. There was a very strong, positive correlation between game and written test scores (r = 0.84, P < 0.01). CONCLUSIONS: These findings contribute validity evidence for PediatricSim game scores to assess knowledge of pediatric emergency medicine resuscitation.

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.

Evaluation of a novel Web-based pediatric advanced life support course.

OBJECTIVE: To assess the educational efficacy of a Web-based pediatric advanced life support course (Web-PALS). DESIGN: Nonrandomized, prospective, cohort study. SETTING: University medical center. PARTICIPANTS: Health care providers (includes physicians, nurses, paramedics, and respiratory therapists) taking either the Web-PALS or a traditional PALS course (Trad-PALS). MAIN EXPOSURE: Web-PALS. MAIN OUTCOME MEASURES: Postcourse written examination scores and scored videotapes of students performing 5 PALS procedures were compared between study groups. Students completed precourse and postcourse questionnaires, rating on a 5-point Likert scale their self-confidence to perform PALS assessments and procedures. A structured, course satisfaction survey was given after students had taken the Web-PALS course. RESULTS: Eighty-six students completed the study (44 Web-PALS and 42 Trad-PALS). All students achieved a passing score on the written examination on their first attempt. Compared with students in the Trad-PALS group, students in the Web-PALS group scored slightly lower (97.1% vs 95.4%; difference, 1.7%; 95% confidence interval, 0.1-3.2). Mean overall videotape scores were similar among the Web-PALS and Trad-PALS groups (75.0% vs 73.0%; difference, 2.0%; 95% confidence interval, -2.0 to 6.0). After completing the Web-PALS course, the mean level of confidence improved from 3.77 to 4.28 (difference, 0.51; 95% confidence interval, 0.33-0.69). Ninety-six percent of respondents indicated that Web-PALS met all of the stated objectives of the PALS course. All respondents indicated that they would recommend Web-PALS to a colleague. CONCLUSIONS: Students perceive Web-PALS as a positive educational experience. Though not identical to students taking the Trad-PALS course, they performed well on postcourse cognitive and psychomotor testing. These findings support Web-PALS as an acceptable format for administering the PALS course.

Qualitative Study Exploring Implementation of a Point-of-Care Competency-Based Lumbar Puncture Program Across Institutions.

OBJECTIVE: To explore the factors that facilitated or hindered successful implementation of a multi-centered infant lumbar puncture (LP) competency-based education program that required interns to demonstrate skills readiness on a task trainer before performing their first clinical LP. METHODS: In 2013, investigators conducted a qualitative study utilizing semistructured interviews and focus groups of site directors (SDs) from the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) who were responsible for implementing the LP competency-based education program. Transcripts were analyzed using grounded theory to identify and verify emergent themes and subthemes. RESULTS: Thematic saturation was attained after interviewing 19 SDs in 12 interviews and 3 focus groups. The most significant strategies and barriers were organized into 4 main themes: 1) alignment of different visions to obtain buy-in, 2) balance between providing education versus patient care, 3) acceptance of novel teaching paradigms, and 4) communication logistics. The ability to overcome barriers was influenced by institutional culture on trainee education, patient safety and research; the level of relational coordination between different groups of stakeholders; and the ability of SDs to identify and diversify entrepreneurial strategies. CONCLUSIONS: INSPIRE SDs reveal the challenges of implementing a network-wide competency-based educational initiative that determines interns' readiness to perform LPs in clinical settings. Strategizing to align the common goals of graduate medical training, patient care and research instructs clinician educators and leaders on how to successfully change educational culture in academic medicine.

Validation of global rating scale and checklist instruments for the infant lumbar puncture procedure.

INTRODUCTION: The Patient Outcomes in Simulation Education network has developed tools for the assessment of competency to perform the infant lumbar puncture (ILP) procedure. The objective of this study was to evaluate the validity and reliability of these tools in a simulated setting. METHODS: We developed a 4-point anchored global rating scale (GRS) and 15-item dichotomous checklist instrument to assess ILP performance in a simulated environment. Video recordings of 60 subjects performing an unsupervised lumbar puncture on an infant bench top simulator were collected prospectively; 20 performed by subjects in each of 3 categories (beginner, intermediate experienced, or expert). Three blinded, expert raters independently scored each subject's video recording using the GRS and checklist instruments. RESULTS: The final version of the scoring instruments is presented. Across all subject groups, higher GRS scores were found with advancing level of experience (P < 0.01). Total checklist scores were similar between the expert and intermediate experienced groups (P = 0.54). Both groups scored higher than the beginner group on the checklist instrument (P < 0.01). For each rater, a significant positive correlation was found between GRS scores and total checklist scores (median ρ = 0.75, P < 0.01). Cronbach α coefficient for the checklist was 0.77. The intraclass correlation coefficients between raters for the GRS and total checklist scores were 0.71 and 0.52, respectively. CONCLUSIONS: This study provides some initial evidence to support the validity and reliability of the ILP-anchored GRS. Acceptable internal consistency was found for the checklist instrument. The GRS instrument outperformed the checklist in its discriminant ability and interrater agreement.

The effect of simulation training on PALS skills among family medicine residents.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that family medicine residents receive structured skills training on pediatric advanced life support (PALS) and should learn procedures for medical emergencies in patients of all ages. Traditional methods of training family medicine residents in PALS is challenging given their limited clinical exposure to critically ill patients. The primary objective of this study was to assess the effect of a 2-hour PALS training session utilizing high-fidelity mannequins on residents' psychomotor skills performances. METHODS: Between February and June 2009, residents from two urban family medicine residency programs received training on four PALS procedures (bag-mask ventilation, tracheal intubation, intraosseous line placement, and cardiac rhythm assessment/defibrillation) at a university simulation center. Residents completed questionnaires to provide data on previous resuscitation training and experience. We collected self-confidence data and video recordings of residents performing the procedures before and after training. To assess retention at 6 months, we collected self-confidence data and video recordings of PGY-1 and PGY-2 residents performing the procedures. A blinded reviewer scored the video recordings. RESULTS: Forty-seven residents completed the study. The majority of residents (53.2%) had never performed any of the procedures on a real patient. Immediately following skills training, mean overall performance improved from 39.5% (± 11.5%) to 76.5% (± 10.4%), difference 37.0% (95% CI, 33.5%--40.6%). Bag-mask ventilation and intraosseous insertion skills remained above baseline at 6-month follow-up. CONCLUSIONS: Simulation training is beneficial for teaching PALS procedures to family medicine residents.