Improving Pediatric Preparedness in Critical Access Hospital Emergency Departments: Impact of a Longitudinal In Situ Simulation Program.

OBJECTIVES: Critical access hospitals (CAH) see few pediatric patients. Many of these hospitals do not have access to physicians with pediatric training. We sought to evaluate the impact of an in situ pediatric simulation program in the CAH emergency department setting on care team performance during resuscitation scenarios. METHODS: Five CAHs conducted 6 high-fidelity pediatric simulations over a 12-month period. Team performance was evaluated using a validated 35-item checklist representing commonly expected resuscitation team interventions. Checklists were scored by assigning zero point for "yes" and 1 point for "no". A lower final score meant more items on the list had been completed. The Kruskal-Wallis rank test was used to assess for differences in average scores among institutions. A linear mixed effects model with a random institution intercept was used to examine trends in average scores over time. P < 0.05 was considered significant. RESULTS: The Kruskal-Wallis rank test showed no difference in average scores among institutions. (P = 0.90). Checklist scores showed a significant downward trend over time, with a scenario-to-scenario decrease of 0.022 (P < 0.01). One hundred percent of providers surveyed in the last month stated they would benefit from ongoing scenarios. CONCLUSIONS: Regularly scheduled pediatric simulations in the CAH emergency department setting improved team performance over time on expected resuscitation tasks. The program was accepted by providers. Implementation of simulation-based training programs can help address concerns regarding pediatric preparedness in the CAH setting. A future project will look at the impact of the program on patient care and safety.

Project CAPE: a high-fidelity, in situ simulation program to increase Critical Access Hospital Emergency Department provider comfort with seriously ill pediatric patients.

OBJECTIVES: Variation exists between the qualities of emergency department (ED) care provided to urban versus rural pediatric patients. We implemented a pediatric simulation program in the Critical Access Hospital (CAH) ED setting and evaluated whether this training would increase provider comfort with seriously ill children. METHODS: Five CAH hospitals conducted 6 scenarios for 12 months. Baseline surveys assessed ED staff exposure to and comfort with children. Surveys were repeated after 6 and 12 months. Respondents' answers were matched longitudinally. Changes in responses over time were analyzed using paired t tests for continuous variables. Changes in frequencies and percentages of categorical variables over time were analyzed using χ test. Scenario participants completed an additional survey at the end of each simulation. RESULTS: The baseline survey was completed by 104 of 150 eligible participants, giving a 71% response rate. Fifty-eight percent completed at least 1 additional survey. On survey 1, mean provider comfort score for procedures was 69 (0-100 point scale). Scores increased 6 points from surveys 1 to 2 and a total of 6.5 points from surveys 1 to 3 (P < 0.05).One hundred fifty postscenario surveys were completed. Of the providers, 83.7% believed that scenario participation increased their comfort with children. One hundred percent of the providers in month 12 felt that they would benefit from additional scenarios. CONCLUSIONS: An in situ pediatric simulation program can be implemented effectively in CAH EDs and results in increased comfort with pediatric patients. Such a program could be used as the core feature of a CAH education program aimed at improving the quality of pediatric emergency services provided at these safety net institutions.

Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method.

Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.