A scoping review of artificial intelligence in medical education: BEME Guide No. 84.

BACKGROUND: Artificial Intelligence (AI) is rapidly transforming healthcare, and there is a critical need for a nuanced understanding of how AI is reshaping teaching, learning, and educational practice in medical education. This review aimed to map the literature regarding AI applications in medical education, core areas of findings, potential candidates for formal systematic review and gaps for future research. METHODS: This rapid scoping review, conducted over 16 weeks, employed Arksey and O'Malley's framework and adhered to STORIES and BEME guidelines. A systematic and comprehensive search across PubMed/MEDLINE, EMBASE, and MedEdPublish was conducted without date or language restrictions. Publications included in the review spanned undergraduate, graduate, and continuing medical education, encompassing both original studies and perspective pieces. Data were charted by multiple author pairs and synthesized into various thematic maps and charts, ensuring a broad and detailed representation of the current landscape. RESULTS: The review synthesized 278 publications, with a majority (68%) from North American and European regions. The studies covered diverse AI applications in medical education, such as AI for admissions, teaching, assessment, and clinical reasoning. The review highlighted AI's varied roles, from augmenting traditional educational methods to introducing innovative practices, and underscores the urgent need for ethical guidelines in AI's application in medical education. CONCLUSION: The current literature has been charted. The findings underscore the need for ongoing research to explore uncharted areas and address potential risks associated with AI use in medical education. This work serves as a foundational resource for educators, policymakers, and researchers in navigating AI's evolving role in medical education. A framework to support future high utility reporting is proposed, the FACETS framework.

A Program of Assessment Model for Point-of-Care Ultrasound Training for Pediatric Critical Care Providers: A Comprehensive Approach to Enhance Competency-Based Point-of-Care Ultrasound Training.

Point-of-care ultrasound (POCUS) is increasingly accepted in pediatric critical care medicine as a tool for guiding the evaluation and treatment of patients. POCUS is a complex skill that requires user competency to ensure accuracy, reliability, and patient safety. A robust competency-based medical education (CBME) program ensures user competency and mitigates patient safety concerns. A programmatic assessment model provides a longitudinal, holistic, and multimodal approach to teaching, assessing, and evaluating learners. The authors propose a fit-for-purpose and modifiable CBME model that is adaptable for different institutions' resources and needs for any intended competency level. This educational model drives and supports learning, ensures competency attainment, and creates a clear pathway for POCUS education while enhancing patient care and safety.

Using starling murmuration as a model for creating a global health community of practice to advance equity in scholarship.

BACKGROUND: Disparities in scholarship exist between authors in low- or middle-income countries (LMIC) and high-income countries. Recognizing these disparities in our global network providing pediatric, adolescent, and maternal healthcare to vulnerable populations in LMIC, we sought to improve access and provide resources to address educational needs and ultimately impact the broader scholarship disparity. METHODS: We created a virtual community of practice (CoP) program underpinned by principles from starling murmuration to promote interdisciplinary scholarship. We developed guiding principles- autonomy, mastery and purpose- to direct the Global Health Scholarship Community of Practice Program. Program components included a continuing professional development (CPD) program, an online platform and resource center, a symposium for scholarship showcase, and peer coaching. RESULTS: From February 2021 to October 2022, 277 individuals joined. Eighty-seven percent came from LMIC, with 69% from Africa, 6% from South America, and 13% from other LMIC regions. An average of 30 members attended each of the 21 CPD sessions. Thirty-nine authors submitted nine manuscripts for publication. The symposium increased participation of individuals from LMIC and enhanced scholarly skills and capacity. Early outcomes indicate that members learned, shared, and collaborated as scholars using the online platform. CONCLUSION: Sharing of knowledge and collaboration globally are feasible through a virtual CoP and offer a benchmark for future sustainable solutions in healthcare capacity building. We recommend such model and virtual platform to promote healthcare education and mentoring across disciplines.

Simulation-based assessment of care for an infant with cardiogenic shock in the emergency department.

BACKGROUND: Congenital heart disease (CHD) is the leading cause of infant deaths associated with birth defects. Neonates with undiagnosed CHD often present to general emergency departments (GEDs) for initial resuscitation that are less prepared than paediatric centres, resulting in disparities in the quality of care. Neonates with undiagnosed CHD represent a challenge; thus, it is necessary for GEDs to be prepared for this population. AIM: To evaluate the process of resuscitative care provided to a neonate in cardiogenic shock due to CHD in the GEDs in a simulated setting and to describe the impact of teams and GED variables on the process of care. METHODS: This is a prospective simulation-based assessment of the process of care provided to a neonate with coarctation of the aorta in cardiogenic shock. Simulation sessions were conducted at participating GEDs utilizing each GED's interdisciplinary team and resources. The primary outcome was adherence to best practice, as measured by a 15-item overall composite adherence score (CAS). In addition, we stratified the overall CAS into CHD-critical items and the general resuscitation items CAS. The secondary outcome was the impact of the team's and GED's characteristics on the scores. RESULTS: This study enrolled 32 teams from 12 GEDs. Among 161 participants, 103 (63.97%) were registered nurses, 33 (20.50%) were physicians, 17 (10.56%) were respiratory therapists, and 8 (4.97%) were other medical professionals. The overall median CAS was 84, with the CHD-critical items having a median CAS of 34.5. The most underperformed tasks are checking pulses on the upper and lower extremities (44%), obtaining blood pressure in the upper and lower extremities (25%), and administering prostaglandin E1 (22%). CONCLUSIONS: Using in situ simulation in a set of GEDs, we revealed gaps in the resuscitation care of neonates with CHD in cardiogenic shock. RELEVANCE TO CLINICAL PRACTICE: These findings highlight the importance of targeted improvement programs for high-stakes illnesses in GED.

The physiology of learning: strategies clinical teachers can adopt to facilitate learning.

Almost all pediatricians working in a hospital or office environment have teaching responsibilities to learners such as medical students and residents. Although teaching and supporting learning in a busy work environment imposes challenges to clinical teachers, these clinical settings provide an ideal setup for experiential learning, learning from daily experiences with patients. Advances in the science of learning derived from various fields have informed us how adults learn best. Many techniques and strategies based on this "physiology of learning" have shown their educational values in everyday pediatric practice. This article outlines how clinical teachers can create the conditions to optimize experiential learning for individual or a group of learners. We highlight practical implications of educational theories and evidence-based educational practices for clinical teachers seeking to enhance their teaching effectiveness. These include promoting active learning and engaging learners in deliberate practice; retrieval of knowledge and prior experiences to enhance motivation; supporting a psychologically safe learning environment; helping learners to set goals; fostering collaborative learning; structuring teaching to link it to authentic roles and tasks; and customizing content to individual learners.Conclusion: Applying adult learning principles in everyday teaching activities will support busy pediatricians to be successful in their tasks as clinical teachers, and contribute to work satisfaction. What is Known: • Most pediatricians provide clinical teaching to medical students and residents, but few have had formal training in educational techniques. • Learning from clinical experiences (experiential learning) is of key importance to becoming and maintaining a competent pediatrician. What is New: • This review presents an up-to-date overview of the physiology of learning, i.e., how people learn. • Knowledge of the principles of how people learn helps pediatricians shape their clinical teaching effectively and contribute to their work satisfaction.

Lessons and Insights From the Implementation of the Cohort Model for a PICU: A Case Study Research.

OBJECTIVES: The subspecialty cohort model allows for creation of smaller diagnosis pools, enabling concentration of expertise and collaboration. Given unknown effects of this model on team dynamics in a PICU, we examined how the cohort-model implementation was perceived by our providers and how this organizational change affected the work environment. DESIGN: Case study research approach consisting of surveys, operational observations, and semistructured interviews. A descriptive survey was derived from an integrated conceptual framework (i.e., teamwork and psychologic safety). Sensitized by the framework and quantitative survey data, we conducted a thematic analysis from field notes and interview data. SETTING: A quaternary-care, children's hospital with a 31-bed PICU. SUBJECTS: PICU providers and nurses and subspecialists. INTERVENTION: Implementation of the subspecialty cohort model. MEASUREMENTS AND MAIN RESULTS: A total of 308 and 269 responses from pre- and postcohort surveys, respectively, were analyzed. Overall, 76% of physicians and 74% of nurses viewed the cohort model favorably. Three themes emerged: community-from disruption to redistribution, transforming identity-expert or generalist, and expansive learning from focused practice. The findings provided insights, informed by a theory of "Community of Practice," as lessons learned and ways to enhance the cohort model. CONCLUSIONS: Our transition to a cohort PICU model offers lessons on impacts of PICU model changes on communities and teams. These theory-informed insights and implications can guide others undergoing similar transitions.

Online learning developments in undergraduate medical education in response to the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 69.

BACKGROUND: The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned. METHODS: The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance. RESULTS: Fifty-six articles were included. The majority (n = 41) described the rapid transition of existing offerings to online formats, whereas fewer (n = 15) described novel activities. The majority (n = 27) included a combination of synchronous and asynchronous components. Didactics (n = 40) and small groups (n = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies (n = 54) assessed reaction/satisfaction, fewer than half (n = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes. CONCLUSIONS: UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71.

BACKGROUND: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners. METHODS: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned. RESULTS: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment. CONCLUSIONS: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Virtual Communication Embedded Bedside ICU Rounds: A Hybrid Rounds Practice Adapted to the Coronavirus Pandemic.

OBJECTIVES: Coronavirus disease 2019 containment strategies created challenges with patient-centered ICU rounds. We examined how hybrid rounds with virtual communication added to in-person rounds could facilitate social distancing while maintaining patient-centered care. DESIGN: Continuous quality improvement. SETTING: Quaternary care referral pediatric hospital. PATIENTS: Daytime rounds conducted on PICU patients. INTERVENTIONS: Following a needs assessment survey and pilot trials, multiple technological solutions were implemented in a series of plan-do-study-act cycles. Hybrid rounds model was deployed where a videoconference platform was used to establish communication between the bedside personnel (nurse, patient/family, and partial ICU team) with remotely located remaining ICU team, ancillary, and consultant providers. Floor labels marking 6-feet distance were placed for rounders. MEASUREMENTS AND MAIN RESULTS: Outcome metrics included compliance with social distancing, mixed methods analysis of surveys, direct interviews of providers and families, and reports of safety concerns. The clinicians adopted hybrid rounds readily. Compliance with social distancing and use of floor labels needed reminders. One-hundred fourteen providers completed the feedback survey. Twenty-five providers and 11 families were interviewed. Feedback about hybrid rounds included inability to teach effectively, suboptimal audio-video quality, loss of situational awareness of patient/unit acuity, alarm interference, and inability to socially distance during other ICU interactions. Benefits noted were improved ancillary input, fewer interruptions, improved efficiency, opportunity to integrate with data platforms, and engage remote consultants and families. Nurses and families appreciated the efforts to ensure safety but wanted the ICU attending/fellow supervising the team to participate at bedside, during rounds. Clinicians appreciated the multidisciplinary input but felt that teaching was difficult. CONCLUSIONS: Hybrid rounds employed during pandemic facilitated social distancing while retaining patient-centered multidisciplinary ICU rounds but compromised teaching during rounds. A change to ingrained rounding habits needs team commitment and ongoing optimization. The hybrid rounds model has potential for generalizability to other settings.

Psychometric validation of the reconstructed version of the assessment of reasoning tool.

BACKGROUND: Assessing learners' competence in diagnostic reasoning is challenging and unstandardized in medical education. We developed a theory-informed, behaviorally anchored rubric, the Assessment of Reasoning Tool (ART), with content and response process validity. This study gathered evidence to support the internal structure and the interpretation of measurements derived from this tool. METHODS: We derived a reconstructed version of ART (ART-R) as a 15-item, 5-point Likert scale using the ART domains and descriptors. A psychometric evaluation was performed. We created 18 video variations of learner oral presentations, portraying different performance levels of the ART-R. RESULTS: 152 faculty viewed two videos and rated the learner globally and then using the ART-R. The confirmatory factor analysis showed a favorable comparative fit index = 0.99, root mean square error of approximation = 0.097, and standardized root mean square residual = 0.026. The five domains, hypothesis-directed information gathering, problem representation, prioritized differential diagnosis, diagnostic evaluation, and awareness of cognitive tendencies/emotional factors, had high internal consistency. The total score for each domain had a positive association with the global assessment of diagnostic reasoning. CONCLUSIONS: Our findings provide validity evidence for the ART-R as an assessment tool with five theoretical domains, internal consistency, and association with global assessment.

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64.

BACKGROUND: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research. METHODS: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts. RESULTS: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement). CONCLUSIONS: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

Learning in Pediatric Emergency Situations: A Qualitative Study of Residents' Perspectives.

OBJECTIVES: To explore resident learning in the context of emergency situations. The guiding research questions were: How do residents learn in emergency situations? What factors facilitate or hinder their learning? DESIGN: A qualitative approach was used in order to understand the different perspectives of participants and explore the context of emergency situations. Aware of the complex sociocultural interactions in emergency situations, we used the methodology of constructivist grounded theory. SETTING: A medium-sized pediatric academic hospital in San Antonio, TX. SUBJECTS: Twenty pediatric residents participated in semi-structured interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used an iterative process of data collection and analysis. The process continued until thematic saturation was reached. The data were coded and analyzed using constant comparison. Codes were clustered into themes informed by the theory of situated learning. Several methods were used to ensure trustworthiness of results. Three main themes were identified. First, resident participation in emergency situations takes different forms. Residents participate mostly in helping roles. Watching is an under-recognized form of participation yet offered unique experiences. Managing roles are rarely afforded to residents. Second, resident participation is informed by the context of the emergency situation. Based on contextual clues (e.g., safety, needs), residents infer potential risks and values from their participation, which guides their participatory role. Residents may shift their form of participation, based on changes in the context. Supervisors play a significant role in guiding resident participation. Third, engagement, a state of cognitive and emotional focus, is critical in learning. The context of the emergency situation plays a role in the level of resident engagement. Supervisors may also foster resident engagement. CONCLUSIONS: Resident participation in emergency situations is complex and informed by the context. Learning in emergency situations is influenced by residents' level of mental engagement. Supervisors may positively guide resident participation, foster engagement, and enable them to reach their learning goals in emergency situations.

Envisioning Distinctive Professional Identity for Critical Care Advanced Practice Providers: Fostering Integrative Transformation Beyond Orientation.

The roles played by nurse practitioners and physician assistants have expanded exponentially during the last decade. Although existing professional advancement models for nurse practitioners/physician assistants have led to enhanced integration in different patient care units, the development of a distinctive professional identity formation is lacking. This perspective proposes a new framework to guide the planning of an educational program that provides not only clinical knowledge and technical skills but also opportunities for enhancing leadership and research skills, along with strong career mentorship. Such a program will lead to formation of a distinctive identity for critical care nurse practitioners and physician assistants, which in turn can improve job satisfaction and employee retention.

A Novel Tool for Teaching Cardiac Point-of-Care Ultrasound: An Exploratory Application of the Design-Based Research Approach.

OBJECTIVES: To develop a competency-based educational tool for cardiac point-of-care ultrasound image interpretation using the design-based research approach. DESIGN: In accordance with design-based research, multiple methods were used to determine that learners would benefit from achieving competency in cardiac point-of-care ultrasound image interpretation before they attempted it at the bedside. A competency-based educational tool was designed and underwent a rapid prototyping process with experts. Evaluative data was used to redesign and reevaluate the educational tool with a new group of learners to improve its effectiveness. SETTING: Large, university-based children's hospital. SUBJECTS: Pediatric critical care attending physicians, fellow physicians and advanced practice providers, and pediatric resident physicians. INTERVENTIONS: Integrating mastery learning and deliberate practice as theoretical frameworks, the authors designed an online "Image Library" composed of 90 questions of cardiac point-of-care ultrasound image clips with varying degrees of pathology that were organized into three levels of difficulty. Learners answered a set of 10 questions, learned from feedback, and repeated an additional set in the same difficulty until achieving a predefined level of mastery. MEASUREMENTS AND MAIN RESULTS: Two learning cycles were implemented with a total of 41 learners. Forty learners (98%) were able to demonstrate mastery on the Image Library and required a range of 30 to 210 questions to do so. On a 10-question final assessment, learners scored an average of 72%, while experts and novices scored 83% and 17%, respectively. On a 5-point scale, learners rated the quality of the Image Library for facilitation of learning (median 5), enjoyment of learning (5), and useful knowledge and skills to improve clinical practice (5). CONCLUSIONS: An effective and innovative tool for teaching cardiac point-of-care ultrasound image interpretation was developed using the design-based research approach. Our results demonstrate the importance of individualized learning timelines for ultrasound image interpretation.

Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME Guide No. 63.

BACKGROUND: The novel coronavirus disease (COVID-19) was declared a pandemic in March 2020. This rapid systematic review synthesised published reports of medical educational developments in response to the pandemic, considering descriptions of interventions, evaluation data and lessons learned. METHODS: The authors systematically searched four online databases and hand searched MedEdPublish up to 24 May 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias for included articles. Discrepancies were resolved by a third author. A descriptive synthesis and outcomes were reported. RESULTS: Forty-nine articles were included. The majority were from North America, Asia and Europe. Sixteen studies described Kirkpatrick's outcomes, with one study describing levels 1-3. A few papers were of exceptional quality, though the risk of bias framework generally revealed capricious reporting of underpinning theory, resources, setting, educational methods, and content. Key developments were pivoting educational delivery from classroom-based learning to virtual spaces, replacing clinical placement based learning with alternate approaches, and supporting direct patient contact with mitigated risk. Training for treating patients with COVID-19, service reconfiguration, assessment, well-being, faculty development, and admissions were all addressed, with the latter categories receiving the least attention. CONCLUSIONS: This review highlights several areas of educational response in the immediate aftermath of the COVID-19 pandemic and identifies a few articles of exceptional quality that can serve as models for future developments and educational reporting. There was often a lack of practical detail to support the educational community in enactment of novel interventions, as well as limited evaluation data. However, the range of options deployed offers much guidance for the medical education community moving forward and there was an indication that outcome data and greater detail will be reported in the future.

Isolating red flags to enhance diagnosis (I-RED): An experimental vignette study.

OBJECTIVE: To investigate effects of a cognitive intervention based on isolation of red flags (I-RED) on diagnostic accuracy of 'do-not-miss diagnoses.' DESIGN: A 2 × 2 randomized case vignette-based experiment with manipulation of I-RED strategy between subjects and case complexity within subjects. SETTING: Two university-based residency programs. PARTICIPANTS: One-hundred and nine pediatric residents from all levels of training. INTERVENTIONS: Participants were randomly assigned to the I-RED vs. control group, and within each group, they were further randomized to the order in which they saw simple and complex cases. The I-RED strategy involved an instruction to look for a constellation of symptoms, signs, clinical data or circumstances that should heighten suspicion for a serious condition. MAIN OUTCOME MEASURES: Primary outcome was diagnostic accuracy, scored as 1 if any of the three differentials given by participants included the correct diagnosis, and 0 if not. We analyzed effects of I-RED strategy on diagnostic accuracy using logistic regression. RESULTS: I-RED strategy did not yield statistically higher diagnostic accuracy compared to controls (62 vs. 48%, respectively; odd ratio = 2.07 [95% confidence interval, 0.78-5.5], P = 0.14) although participants reported higher decision confidence compared to controls (7.00 vs. 5.77 on a scale of 1 to 10, P < 0.02) in simple but not complex cases. I-RED strategy significantly shortened time to decision (460 vs. 657 s, P < 0.001) and increased the number of red flags generated (3.04 vs. 2.09, P < 0.001). CONCLUSIONS: A cognitive strategy of prompting red flag isolation prior to differential diagnosis did not improve diagnostic accuracy of 'do-not-miss diagnoses.' Given the paucity of evidence-based solutions to reduce diagnostic error and the intervention's potential effect on confidence, findings warrant additional exploration.

Cardiac and lung point-of-care ultrasound in pediatric anesthesia and critical care medicine: Uses, pitfalls, and future directions to optimize pediatric care.

Point-of-care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.

Risk Factors for Ventilator-Associated Events in a PICU.

OBJECTIVE: The term ventilator-associated events includes ventilator-associated condition, infection-related ventilator-associated complication, and ventilator-associated pneumonia. We sought to identify potential new risk factors for ventilator-associated condition and infection-related ventilator-associated complication in the PICU population. DESIGN: Matched case control study. SETTING: Children's hospital at a tertiary care academic medical center. PATIENTS: During the study period, 606 patients were admitted to PICU and ventilated more than 48 hours; 70 children met ventilator-associated condition criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied the definition for ventilator-associated condition (i.e., a sustained increase in ventilator settings after a period of stable or decreasing support) to our database. Within ventilator-associated condition cases, 40 cases were infection-related ventilator-associated complication and 30 cases were noninfectious-related ventilator-associated condition. We identified 140 controls and matched to ventilator-associated condition cases with regard to age, immunocompromised status, and ventilator days to event. Patients with ventilator-associated condition had longer ICU stay versus controls; 24 days median (12-43 interquartile range) versus 7 days (4-14); (p < 0.01), respectively, and longer duration of ventilatory support 17 days (10-32) versus 6 days (3-10); p < 0.01, respectively. Mortality was 22.8% in the ventilator-associated condition versus 9% in the control group (p < 0.01). A multivariate regression analysis adjusted for Pediatric Index of Mortality 2 identified mean peak inspiratory pressure and acute kidney injury to be associated with ventilator-associated condition (odds ratio, 1.12 [95% CI, 1.02-1.22] and odds ratio, 2.85 [1.43-5.66], respectively). Acute kidney injury and neuromuscular blockade in a multivariate regression analysis adjusted for Pediatric Index of Mortality 2 were associated with infection-related ventilator-associated complication (odds ratio, 2.36 [1.03-5.40] and 3.19 [1.17-8.68], respectively). CONCLUSIONS: There is an association between ventilator-associated condition and infection-related ventilator-associated complication in critically ill children with acute kidney injury, ventilatory support, and neuromuscular blockade. Attention should be given by clinical practitioners to recognize these modifiable risk factors and to implement strategies to decrease the prevalence of ventilator-associated events.