Usability Testing Via Simulation: Optimizing the NEAR4PEM Preintubation Checklist With a Human Factors Approach.

OBJECTIVES: To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist. METHODS: This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist. RESULTS: Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist. CONCLUSIONS: Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.

Impact of the COVID-19 Pandemic on Low-Value Testing and Treatment of Bronchiolitis.

BACKGROUND: Viral testing and treatments such as systemic steroids and inhaled corticosteroids are low-value care for routine bronchiolitis. We sought to determine the impact of the COVID-19 pandemic on low-value care in young children with bronchiolitis. METHODS: This was a retrospective, cross-sectional study using the Pediatric Health Information Systems database. We included children <2 years seen in a pediatric emergency department for bronchiolitis. We selected a priori 3 study periods: September 2018 to February 2020 (prepandemic), March 2020 to August 2022 (early pandemic), and September 2022 to January 2023 (late pandemic). Low-value care included respiratory syncytial virus testing, chest radiography, albuterol, or corticosteroids and was compared across the 3 time periods. RESULTS: At least 1 element of low-value care was provided in 45%, 47%, and 44% of encounters in the prepandemic, early pandemic, and late pandemic periods, respectively. There was little variation in the use of albuterol and chest radiography across time periods and a slight increase in systemic corticosteroid use from prepandemic to early and late pandemic groups. Viral testing increased from 36% prepandemic to 65% early pandemic and 67% late pandemic, which appeared to be driven by SARS-CoV-2 testing and combination viral testing. CONCLUSIONS: There was no clinically significant change in low-value care for bronchiolitis during the pandemic. Because of SARS-CoV-2 testing, however, overall frequency of viral testing increased dramatically over time. This marked increase in overall viral testing should be taken into consideration for future quality improvement efforts.

Rapid cycle deliberate practice to improve airway skills and performance of trainees in a pediatric emergency department.

Objective: The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows. Methods: We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review). Results: During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p = 0.028) and shorter attempt duration (22 s vs. 29 s, p = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p = 0.231). Conclusions: At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows.

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department.

OBJECTIVES: The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork. METHODS: This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool. RESULTS: We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007). CONCLUSIONS: Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation.

Background: Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods: Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results: Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions: This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.

The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children.

STUDY OBJECTIVE: Our study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department. METHODS: We conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models. RESULTS: Proceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization-by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7). CONCLUSIONS: Emergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.

Making a move: Using simulation to identify latent safety threats before the care of injured patients in a new physical space.

BACKGROUND: In today's rapidly changing health care environment, hospitals are expanding into newly built spaces. Preserving patient safety by identifying latent safety threats (LSTs) in advance of opening a new physical space is key to continued excellent care. At our level 1 pediatric trauma center, the hospital undertook a 5-year project to build a critical care tower, including a new emergency department with five trauma bays. To allow for identification and mitigation of LSTs before opening, we performed simulation-based clinical systems testing. METHODS: Eight simulation scenarios were developed, based on actual patient presentations, incorporating a variety of injury patterns. Scenarios included workflow and movement from the helipad and squad entrance as well as to radiology, the operating room, and the pediatric intensive care unit. A multiple resuscitation scenario was also designed to test the use of all five bays simultaneously. Multidisciplinary high-fidelity simulations were conducted in the new tower. Key trauma and emergency department stakeholders facilitated all sessions, using a structured framework for systems integration debriefing framework and failure mode and effect analysis to identify and prioritize LSTs, respectively. RESULTS: Eight sessions were conducted for 2 months. A total of 201 staff participated, including trauma surgeons, respiratory therapists, nurses, emergency physicians, x-ray technicians, pharmacists, emergency medical services, and operating room staff. In total, 118 LSTs (average of 14.8/session) were identified. Latent safety threats were categorized. An action plan for mitigation was developed after applying failure mode and effects analysis prioritization scores (based on severity, probability, and ease of detection). CONCLUSION: Systems-focused trauma simulations identified a large number of LSTs before the opening of a new critical care building. Identification of LSTs is feasible and facilitates mitigation before actual patient care begins, improving patient safety. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The Concise Assessment of Leader Management Tool: Evaluation of Healthcare Provider Leadership During Real-Life Pediatric Emergencies.

INTRODUCTION: Resuscitation events in pediatric critical and emergency care are high risk, and strong leadership is an important component of an effective response. The Concise Assessment of Leadership Management (CALM) tool, designed to assess the strength of leadership skills during pediatric crises, has shown promising validity and reliability in simulated settings. The objective of this study was to generate further validity and reliability evidence for the CALM by applying it to real-life emergency events. METHODS: A prospective, video-based study was conducted in an academic pediatric emergency department. Three reviewers independently applied the CALM tool to the assessment of pediatric emergency department physicians as they led both a cardiac arrest and a sepsis event. Time to critical event (epinephrine, fluid, and antibiotic administration) was collected via video review. Based on Kane's framework, we conducted fully crossed, person × event × rater generalizability (G) and decision (D) studies. Interrater reliability was calculated using Gwet AC 2 and intraclass correlation coefficients. Time to critical events was correlated with CALM scores using Spearman coefficient. RESULTS: Nine team leaders were assessed in their leadership of 2 resuscitations each. The G coefficient was 0.68, with 26% subject variance, 20% rater variance, and no case variance. Thirty-three percent of the variance (33%) was attributed to third-order interactions and unknown factors. Gwet AC 2 was 0.3 and intraclass correlation was 0.58. The CALM score and time to epinephrine correlated at -0.79 ( P = 0.01). The CALM score and time to fluid administration correlated at -0.181 ( P = 0.64). CONCLUSIONS: This study provides additional validity evidence for the CALM tool's use in this context if used with multiple raters, aligning with data from the previous simulation-based CALM validity study. Further development may improve reliability. It also serves as an exemplar of the rigors of conducting validity work within medical simulation.

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.

STUDY OBJECTIVE: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine.

Background: Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods: This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results: There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions: The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Implementation of a Pediatric Emergency Department Cardiopulmonary Resuscitation Quality Bundle.

BACKGROUND AND OBJECTIVES: We have previously demonstrated that standardized handoff from prehospital to hospital clinicians can improve cardiopulmonary resuscitation performance for out-of-hospital cardiac arrest (OHCA) patients in a pediatric emergency department (ED). We leveraged our previous quality improvement initiative to standardize performance of a bundle of 5 discrete aspects of resuscitation for OHCA patients: intravenous or intraosseous catheter (IV/IO) access, epinephrine administration, advanced airway placement, end-tidal capnography (ETCO2) application, and cardiac rhythm verbalization. We aimed to reduce time to completion of the bundle from 302 seconds at baseline to less than 120 seconds within 1 year. METHODS: A multidisciplinary team performed video-based review of actual OHCA resuscitations in our pediatric ED. We designed interventions aimed at key drivers of bundle performance. Interventions included specific roles and responsibilities and a standardized choreography for each bundle element. To assess the effect of the interventions, time to performance of each bundle element was measured by standardized review of video recordings from our resuscitation bay. Balancing measures were time off the chest and time to defibrillator pad placement. RESULTS: We analyzed 56 cases of OHCA from May 2019 through May 2021. Time to bundle completion improved from a baseline of 302 seconds to 147 seconds. Four of 5 individual bundle elements also demonstrated significant improvement. These improvements were sustained without any negative impact on balancing measures. CONCLUSIONS: Standardized choreography for the initial minutes of ED cardiac arrest resuscitation shows promise to decrease time to crucial interventions in children presenting to the pediatric ED with OHCA.

Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation.

OBJECTIVE: Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). DESIGN: This was a retrospective, observational study of RSI. SETTING: An academic PED. PATIENTS: A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. MEASUREMENT AND MAIN RESULTS: Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. CONCLUSIONS: We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.

Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department.

STUDY OBJECTIVE: Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS: We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS: From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION: We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.

Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative.

Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative. METHODS: There were 3 study periods: baseline (April 2009-March 2010), improvement (July 2012-December 2013), and operational (January 2014-December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts. RESULTS: We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period. CONCLUSIONS: Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department.

ABSTRACT: Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

Acute Flaccid Myelitis: A Multidisciplinary Protocol to Optimize Diagnosis and Evaluation.

Acute flaccid myelitis is an emerging neurologic disease, first described in 2014 and predominantly affecting young children. Acute flaccid myelitis cases tend to spike every 2 years, in the late summer to fall, and the next peak is expected in 2020. The diagnosis of acute flaccid myelitis is often delayed, leading to suboptimal evaluation, including incomplete laboratory assessment. Acute and chronic morbidity are high, and a standardized, multidisciplinary approach to evaluation and treatment is essential to optimizing outcomes. In a review of acute flaccid myelitis patients treated in 2018 at our institution, we noted considerable variability in days to presentation, evaluation, and treatment. In response, the authors developed a protocol for the evaluation and management of pediatric patients suspected of having acute flaccid myelitis. The protocol was developed using local experience/case review, expert consensus, and the relevant literature. The protocol spans the spectrum of care, from initial evaluation in a primary care or emergency setting, to acute hospital management and evaluation and long-term inpatient and rehabilitation settings. The purpose of this report is both to share the findings from our 2018 case review and to disseminate our acute flaccid myelitis protocol. Our hope is that publication of our protocol will both inform the development of a standardized approach to acute flaccid myelitis and to encourage other centers to form a multidisciplinary acute flaccid myelitis team to provide expert care throughout the disease process, from presentation to recovery.