Feasibility of text message follow-up for pediatric asthma care after an emergency department visit.

Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.

SIMPEDVR: using VR in teaching pediatric emergencies to undergraduate students-a pilot study.

The objective of this work was to provide pilot data on feasibility of using virtual reality (VR) to train undergraduate students in pediatric emergency scenarios. We staged VR sessions for a total of 45 medical and nursing students; in every session, each student managed two pediatric emergency virtual scenarios. At the end of the sessions, students completed a Technology Assessment Questionnaire to evaluate the perceived usefulness and perceived ease-of-use of their VR training experience and rated their perceived level of competence in managing the two clinical scenarios. The median perceived usefulness was 91.7/100 (interquartile range (IQR) 80.6-100), while the median perceived ease-of-use was 77.8/100 (IQR 63.9-88.9). The perceived level of competence increased from 2 (IQR 1-3) to 4 (IQR 3-4) on a 5-point Likert scale, for both scenarios (p < 0.001, Wilcoxon test for paired samples).       Conclusions: The staged VR sessions had a good perceived usefulness and resulted in an increase in the perceived level of competence. The results on the ease-of-use, however, show that an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made; further work is required to ease the integration of VR into curricula. What is Known: • Virtual reality (VR) is a rising simulation training methodology in Pediatric Emergency Medicine (PEM), however little experience is reported about its use for undergraduate students What is New: • VR PEM trainiing was found useful by undergraduate students and its use increased their perceived level of competence, although ease-of-use received lower ratings. • Despite the young age, an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY) Study: Secondary Workload and Provider Outcomes in a Simulation-Based Trial.

OBJECTIVES: An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use. DESIGN: Simulation-based randomized trial, conducted from May to December 2021. SETTING: Four pediatric simulation centers. SUBJECTS: Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). INTERVENTIONS: Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales. MEASUREMENTS AND MAIN RESULTS: A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand (p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales (p < 0.05). CONCLUSIONS: The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.

Suctioning in the management of bronchiolitis: A prospective observational study.

BACKGROUND: Bronchiolitis accounts for a considerable number of Emergency Department (ED) visits by infants each year and is the leading cause of respiratory infection in children 2 years of age and younger. Suctioning remains one of the main supportive treatments, but suctioning practices of nasal aspiration and deep suctioning vary among practitioners in bronchiolitis management. Our objective was to explore associations between suction type and respiratory distress, oxygen saturation, and markers of respiratory compromise such as airway escalation, disposition, ED length of stay (LOS), and outpatient outcomes. METHODS: This was a prospective observational study on infants (aged 2-23 months) in a pediatric ED with bronchiolitis from September 2022 to April 2023. Infants with tracheostomies, muscular weakness, and non-invasive positive pressure ventilation were excluded. Infants were grouped into nasal aspiration, deep suctioning, or combination groups. Mean differences in respiratory scores (primary outcome) and oxygen saturation were measured at three timepoints: pre-suction, 30 and 60 min post-suction. Escalation to airway adjuncts, disposition, and ED LOS were also recorded. Discharged families were contacted for phone call interviews. RESULTS: Of 121 enrolled infants (nasal aspiration n = 31, deep suctioning n = 68, combination n = 22), 48% (n = 58) were discharged, and 90% (n = 52) completed the study call. There was no interaction between suction type and timepoint (p = 0.63) and no effect between suction type and respiratory score (p = 0.38). However, timepoint did have an effect on respiratory score between 0 and 30 min post-suction (p = 0.01) and between 0 and 60 min post-suction (p < 0.001). Admitted infants received more deep suctioning or a combination of suctioning compared to those discharged (p = 0.005). Suction type had no effect on oxygen saturation, airway adjunct escalation, length of stay, or outpatient outcomes (p > 0.11). CONCLUSIONS: There was no difference in respiratory scores or outpatient outcomes between suction types. Deep suctioning may not be needed in all infants with bronchiolitis.

Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia.

OBJECTIVE: Infants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for morbidity/mortality arising from life-threatening adrenal crisis. Management of acute illnesses in CAH requires an understanding of factors leading to emergency department (ED) visits and hospitalizations in the first few years of life. We, therefore, examined adrenal crisis at prehospital and ED stages of illness in young children with CAH as they related to medical outcomes. PATIENTS AND DESIGN: Retrospective cohort study of 39 children with CAH due to 21-hydroxylase deficiency (0-4 years of age) and 27 age-matched controls. MEASUREMENTS: ED visit, acute illness symptoms (fever, vomiting, diarrhoea) and other characteristics (hospitalizations, administration of stress-dose hydrocortisone, electrolyte abnormalities). RESULTS: CAH infants and toddlers had significantly higher rates of ED visits (0.50 [0.25-0.88] per person-year) than controls (0 [0-0] per person-year; p < .001). Moreover, CAH children under 6 months old had significantly higher rates of ED visits compared with older ages. Only 50% (51/102) of illness-related ED visits in CAH children were preceded by the administration of either oral (46/51) or intramuscular (11/51) stress dosing by parents. A total of 10.8% of ED visits resulted in hospital admission. Controlling for age and 17-hydroxyprogesterone at diagnosis, electrolyte abnormalities and administration of parenteral hydrocortisone in the ED significantly predicted hospital admission. Receiving a hydrocortisone injection before the ED was a significant predictor of having electrolyte abnormalities. CONCLUSIONS: Infants and toddlers with classical CAH are at high risk for acute illness and hospitalizations and often do not receive adequate stress dosing before the ED.

Optimizing Surgical Performance Using Preoperative Virtual Reality Planning: A Systematic Review.

BACKGROUND: Surgery is often a complex process that requires detailed 3-dimensional anatomical knowledge and rigorous interplay between team members to attain ideal operational efficiency or "flow." Virtual Reality (VR) represents a technology by which to rehearse complex plans and communicate precise steps to a surgical team prior to entering the operating room. The objective of this study was to evaluate the use of VR for preoperative surgical team planning and interdisciplinary communication across all surgical specialties. METHODS: A systematic review of the literature was performed examining existing research on VR use for preoperative surgical team planning and interdisciplinary communication across all surgical fields in order to optimize surgical efficiency. MEDLINE, SCOPUS, CINAHL databases were searched from inception to July 31, 2022 using standardized search clauses. A qualitative data synthesis was performed with particular attention to preoperative planning, surgical efficiency optimization, and interdisciplinary collaboration/communication techniques determined a priori. Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed. All included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool. RESULTS: One thousand and ninety-three non-duplicated articles with abstract and full text availability were identified. Thirteen articles that examined preoperative VR-based planning techniques for optimization of surgical efficiency and/or interdisciplinary communication fulfilled inclusion and exclusion criteria. These studies had a low-to-medium methodological quality with a MERSQI mean score of 10.04 out of 18 (standard deviation 3.61). CONCLUSIONS: This review demonstrates that time spent rehearsing and visualizing patient-specific anatomical relationships in VR may improve operative efficiency and communication across multiple surgical specialties.

Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children.

BACKGROUND: Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE: Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS: We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS: We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS: There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department.

BACKGROUND: Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE: To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS: We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS: Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION: A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.

Children with under-diagnosed asthma presenting to a pediatric emergency department.

BACKGROUND: Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits. OBJECTIVE: To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics. METHODS: We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model. RESULTS: Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (all p < 0.05). Among undiagnosed children, 42% had moderate or severe asthma and 66% reported ≥1 exacerbation in the prior 12 months. Parent-reported controller medication use was higher among diagnosed versus undiagnosed children (60% vs. 21%, p=.001). In a multivariable logistic regression (adjusting for insurance, education, income and preferred language), no controller usage (aOR 4.26), no asthma exacerbations in the prior year (aOR 2.41) and younger age (aOR 0.76) were significantly associated with undiagnosed asthma. CONCLUSION: Children presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound.

ABSTRACT: Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

Parental preferences for survey mode of administration, interview versus self-administered, with an asthma management questionnaire.

Background: National asthma guidelines encourage use of patient surveys to aid clinical assessment. Little is known about how these should be administered in acute care settings such as the emergency department (ED).Objective: Evaluate if parents have a preference for interview versus self-administered surveys in an ED, understand the sociodemographic and clinical characteristics by choice of survey mode of administration, and assess if there is a difference by mode in the parent's perception of an asthma management tool.Methods: A research assistant (RA) surveyed parents of children 2-17 years of age seeking ED asthma care. Parents chose to either self-administer or have an RA-administered survey that included the Pediatric Asthma Control and Communication Instrument-ED version (PACCI-ED). We compared sociodemographic and clinical characteristics and perceptions about the PACCI-ED by mode of survey administration.Results: Of 174 parent participants, 60% chose interviewer-administered surveys. Parents who chose interviewer-administered versus self-administered surveys had lower income, lower educational attainment, and children with uncontrolled asthma (p < .05). Bivariate and multivariate analyses showed that parents who chose interviewer-administered versus self-administered surveys tended to rate the PACCI-ED more favorably.Conclusions: EDs wishing to systematically use an asthma survey may need to plan appropriate resources for staff to administer them, particularly if they serve populations of lower socioeconomic status.

Impact of Environmental Noise Levels on Endotracheal Intubation Performance Among Pediatric Emergency Providers: A Simulation Study.

BACKGROUND: The emergency department is a stressful workplace environment with environmental stimuli and distractions, including noise. This has potential effects on perceived stress for providers and critical procedure performance. OBJECTIVE: This study aimed to characterize the impact of environmental noise levels on the time to intubate, the quality of intubation, and physiologic stress response in pediatric emergency department providers. METHODS: This was a randomized control simulation-based study in which experienced pediatric providers intubated an adult manikin 3 times while experiencing 3 different ambient noise levels (60, 75, 80 dB) in random order. Participants' times to intubate were measured, as was the endotracheal tube depth. The quality of each intubation attempt was assessed via video review against a standardized checklist. Lastly, participants' heart rates were monitored in real time to assess for physiologic stress response. Differences in performance were analyzed using a repeated-measures analysis of variance. RESULTS: No significant difference was found between noise levels and time to intubate (P = 0.19), although each subsequent attempt shortened the time to intubate (P = 0.01). Physiological heart rate changes did not differ by noise level (P = 0.35). Subjectively, "time and economy of motion" and "overall performance" did not differ by noise level but did improve for each subsequent attempt number (P < 0.046). CONCLUSIONS: Intubation performance improved with attempt number, but no differences in performance were seen between noise levels. This suggests that rehearsing and practice impacts performance more than environmental noise levels.

Teaching Infant Cardiopulmonary Resuscitation to Caregivers in the Emergency Department.

OBJECTIVES: Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting. METHODS: Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured. RESULTS: Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings. CONCLUSIONS: Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care.

OBJECTIVES: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks. METHODS: The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS: Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings. CONCLUSIONS: The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.

The Addition of Anaerobic Blood Cultures for Pediatric Patients with Concerns for Bloodstream Infections: Prevalence and Time to Positive Cultures.

Anaerobes are an important but uncommon cause of bloodstream infections (BSIs). For pediatric patients, routine inclusion of an anaerobic blood culture alongside the aerobic remains controversial. We implemented automatic anaerobic blood culture alongside aerobic blood cultures in a pediatric emergency department (ED) and sought to determine changes in recovery of obligate and facultative anaerobes. This was a cohort study in a pediatric ED (August 2015 to July 2018) that began in February 2017. Blood culture positivity results for true pathogens and contaminants were assessed, along with a secondary outcome of time to positivity (TTP) of blood culture. A total of 14,180 blood cultures (5,202 preimplementation and 8,978 postimplementation) were collected, with 8.8% (456) and 7.1% (635) positive cultures in the pre- and postimplementation phases, respectively. Of 635 positive cultures in the postimplementation phase, aerobic blood cultures recovered 7.6% (349/4,615), whereas anaerobic blood cultures recovered 6.6% (286/4,363). In 211/421 (50.0%) paired blood cultures, an organism was recovered in both cultures. The number of cases where organisms were only recovered from an aerobic or an anaerobic bottle in the paired cultures were 126 (30.0%) and 84 (20.0%), respectively. The TTP was comparable regardless of bottle type. Recovery of true pathogens from blood cultures was approximately 7 h faster than recovery of contaminants. Although inclusion of anaerobic blood cultures only recovered 2 (0.69%) obligate anaerobes, it did allow for recovery of clinically significant pathogens that were negative in aerobic blood cultures and supports the routine collection of both bottles in pediatric patients with a concern of bloodstream infections.

Barriers to Effective Teamwork Relating to Pediatric Resuscitations: Perceptions of Pediatric Emergency Medicine Staff.

BACKGROUND: In the pediatric emergency department (PED), resuscitations require medical teams form ad hoc, rarely communicating beforehand. Literature has shown that the medical community has deficiencies in communication and teamwork. However, we as medical providers do not know or understand the perceived barriers of our colleagues. Physicians may perceive a barrier that is different from nurses, respiratory therapists, pharmacists, or technicians. Perhaps we do not know in which area of teamwork and communication we are deficient. Only when we understand the perceptions of our fellow coworkers can we take steps toward improvement in quality resuscitations and therefore patient safety. OBJECTIVE: The primary objectives of this study were to describe and understand the perceived barriers to effective communication and teamwork among different disciplines forming spontaneous resuscitation teams at a tertiary urban PED and to determine if providers of different disciplines perceived these barriers differently. METHODS: This was a mixed-methods study conducted in a single, tertiary care freestanding children's hospital emergency department. Survey questions were iteratively developed to measure the construct of barriers and best practices within resuscitation teamwork, which was administered to staff among 5 selected roles: physicians, nurses, respiratory technicians, PED technicians, and PED pharmacists. It contained open-ended questions to provide statements on specific barriers or goals in effective teamwork, as well as a priority ranking on 25 different statements on teamwork extracted from the literature. From the participant data, 9 core themes related to resuscitation teamwork were coalesced using affinity diagramming by the authors. All statements from the survey were coded to the 9 core themes by 2 authors, with high reliability (κ = 0.93). Descriptive statistics were used to summarize the prevalence of themes mentioned by survey participants. A χ test was used to determine differences in prevalence of core themes by role. Rank data for the 25 statements were converted to a point system (5 points for most important, 4 points for second most important, etc), and a mixed within-between analysis of variance was used to determine the association of role and relative rank. RESULTS: There were 125 respondents (62% response rate) who provided 893 coded statements. The core theme of communication-in particular, closed-loop communication-was the most prevalent theme, although no differences in the proportion of themes represented were seen by PED staff of different roles (P = 0.18). There was a significant effect from the core theme (P = 0.002, partial η = 0.13), with highest priority on team leader performance (mean points out of 5 = 2.5 ± 1.9), but neither effect nor interaction with role (P = 0.6, P = 0.7). CONCLUSIONS: When answering open-ended questions regarding barriers to effective resuscitations, all disciplines perceived communication, particularly closed-loop communication, as the primary theme lacking during resuscitations. However, when choosing from a list of themes, all groups except physicians perceived deficiencies in team leader qualities to be the greatest barrier. We as physicians must work on improving our communication and leadership attributes if we want to improve the quality of our resuscitations.

Attitudes and Opinions of Adolescent Females Regarding 2 Methods of Bladder Filling for Transabdominal Ultrasound: A Q-Sort Study.

OBJECTIVES: Adolescent female patients who are not sexually active and who present to a pediatric emergency department with abdominal pain require a full bladder prior to transabdominal ultrasound. Procedures to fill the bladder are largely institution or provider dependent. We examined adolescent females' attitudes and opinions toward 2 common methods of bladder filling, intravenous fluid administration and transurethral Foley catheter placement, by means of a Q-sort study. METHODS: Two convenience samples of adolescent female patients in the pediatric emergency department at an academic children's hospital participated in the study. In part 1, subjects underwent a semistructured interview to elicit their opinions regarding 2 methods of bladder filling: intravenous fluid or transurethral catheter. The summation of subject statements was then narrowed down to a final Q set of 25 statements. In part 2, a second sample of subjects independently arranged this Q set according to their own agreement or disagreement with each statement. Principal components analysis was conducted to examine factors or collections of statements representing a shared viewpoint and to describe commonalities. RESULTS: Part 1 was completed with 9 subjects, and part 2 with 26 subjects. Factors revealed from the Q-sort data included acceptance of tests deemed medically necessary, desire for parental involvement, and a wish to minimize discomfort. Most adolescents aligned with 1 of these 3 factors. CONCLUSIONS: Adolescent female patients varied in their attitudes and opinions regarding intravenous catheter hydration and Foley catheter placement for transabdominal ultrasound. Knowledge of adolescent viewpoints may help better inform practitioner-patient communication for this procedure.

A National Patient Safety Curriculum in Pediatric Emergency Medicine.

BACKGROUND: Patient safety has become an important and required topic in medical education. A needs assessment showed that pediatric emergency medicine program directors were interested in a common pediatric emergency-specific safety curriculum. OBJECTIVE: The objective of this study was to describe the development and performance of a web-based patient safety curriculum in pediatric emergency medicine. METHODS: A web-based curriculum was created by the Committee on Quality Transformation of the Section of Emergency Medicine for the American Academy of Pediatrics. The curriculum consisted of emergency-specific safety topic didactic sessions with a pretest and posttest assessment. Vignette-based scenarios were also included and were discussed locally by the program directors. RESULTS: Fifty-two percent (37/71) of US Pediatric Emergency Medicine fellowship programs enrolled their fellows in the patient safety curriculum. Overall, 183 Pediatric Emergency Medicine fellows participated in the curriculum. Only 22% (40/183) of fellow participants completed the entire curriculum. The curriculum showed significant improved safety knowledge based upon the pretest and posttest results. Sixty-five percent of responders thought more about safety topics after the curriculum was completed, and 85% witnessed a safety event in the past month, whereas only 48% reported them. CONCLUSIONS: An online centralized curriculum is an effective platform for teaching content in quality and safety to a national group of physicians. Local oversight by program directors may improve compliance with curriculum completion.

Utilization of just-in-time training for nursing education using the LA Phonospirometry asthma tool.

OBJECTIVE: Just-in-time training (JITT) has been used to teach and re-teach known medical techniques, but has not been used to teach novel techniques. We aimed to assess the performance retention of JITT on a novel asthma exacerbation severity assessment technique known as Los Angeles (LA) Phonospirometry. METHODS: This was a prospective cohort study using a convenience sample of pediatric emergency department registered nurses (RNs) who were asked to watch a brief instructional digital video on LA Phonospirometry, and then asked to practice the technique on a research assistant (RA). A checklist was used to evaluate proficiency with the primary outcome being the number correct on the checklist. The secondary outcome included whether or not they could identify a common error demonstrated by the RA. RNs were re-tested after 4-6 months to assess skill retention. RESULTS: Forty RNs were enrolled in the study and six were lost to follow-up. The mean time from the first to second testing was 5.4 months ± 0.5 months. The mean score of the first part of the checklist on the initial testing was 4.6 ± 0.7 and on second testing was 3.8 ± 1.5 (p = 0.008). This represented a drop in scores and thus minimal knowledge decay of 18% (from 91% to 73%). The mean values for number of errors picked up for the first test and second test were 1.3 and 1.5, respectively (p = 0.2). CONCLUSIONS: JITT demonstrated feasibility as a rapid instructional tool for RNs, with a limited decay in cognitive knowledge surrounding the LA Phonospirometry technique.