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.

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 assessment of a manikin-based low-dose, high-frequency cardiac resuscitation quality improvement program in early UK adopter hospitals.

BACKGROUND: Adult and paediatric basic life support (BLS) training are often conducted via group training with an accredited instructor every 24 months. Multiple studies have demonstrated a decline in the quality of cardio-pulmonary resuscitation (CPR) performed as soon as 3-month post-training. The 'Resuscitation Quality Improvement' (RQI) programme is a quarterly low-dose, high-frequency training, based around the use of manikins connected to a cart providing real-time and summative feedback. We aimed to evaluate the effects of the RQI Programme on CPR psychomotor skills in UK hospitals that had adopted this as a method of BLS training, and establish whether this program leads to increased compliance in CPR training. METHODS: The study took place across three adopter sites and one control site. Participants completed a baseline assessment without live feedback. Following this, participants at the adopter sites followed the RQI curriculum for adult CPR, or adult and infant CPR. The curriculum was split into quarterly training blocks, and live feedback was given on technique during the training session via the RQI cart. After following the curriculum for 12/24 months, participants completed a second assessment without live feedback. RESULTS: At the adopter sites, there was a significant improvement in the overall score between baseline and assessment for infant ventilations (N = 167, p < 0.001), adult ventilations (n = 129, p < 0.001), infant compressions (n = 163, p < 0.001) adult compressions (n = 205, p < 0.001), and adult CPR (n = 249, p < 0.001). There was no significant improvement in the overall score for infant CPR (n = 206, p = 0.08). Data from the control site demonstrated a statistically significant improvement in mean score for adult CPR (n = 22, p = 0.02), but not for adult compressions (N = 18, p = 0.39) or ventilations (n = 17, p = 0.08). No statistically significant difference in improvement of mean scores was found between the grouped adopter sites and the control site. The effect of the duration of the RQI curriculum on CPR performance appeared to be minimal in this data set. Compliance with the RQI curriculum varied by site, one site maintained hospital compliance at 90% over a 1 year period, however compliance reduced over time at all sites. CONCLUSIONS: This data demonstrated an increased adherence with guidelines for high-quality CPR post-training with the RQI cart, for all adult and most infant measures, but not infant CPR. However, the relationship between a formalised quarterly RQI curriculum and improvements in resuscitation skills is not clear. It is also unclear whether the RQI approach is superior to the current classroom-based BLS training for CPR skill acquisition in the UK. Further research is required to establish how to optimally implement the RQI system in the UK and how to optimally improve hospital wide compliance with CPR training to improve the outcomes of in-hospital cardiac arrests.

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.

Self-assessment of team performance using T-NOTECHS in simulated pediatric trauma resuscitation is not consistent with expert assessment.

BACKGROUND: The Trauma NOn-TECHnical Skills (T-NOTECHS) tool has been used to assess teamwork in trauma resuscitation, but its reliability and validity for self-assessment is unknown. Our purpose was to determine the reliability and validity of self-administered T-NOTECHS in pediatric trauma resuscitation. METHODS: Simulated in situ resuscitations were evaluated using T-NOTECHS in real time by experts and immediately afterwards by team members. Reliability was analyzed with linear-weighted kappa and intra-class correlation. T-NOTECHS scores were compared between expert (gold-standard) and self-assessment. RESULTS: Fifteen simulations were examined. T-NOTECHS scores were similar between self- and expert assessment for leadership. Self-assessment scores were higher than expert for the other domains and total composite score. Inter-rater reliability for total score was similar between the two groups, but differences were observed in the domains. CONCLUSIONS: Self-assessment is not interchangeable with expert rating when using T-NOTECHS. Future studies need to determine how self-assessment can be best utilized. LEVEL OF EVIDENCE: Studies of diagnostic accuracy - Level 2.

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department.

OBJECTIVE: Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool. METHODS: Video recordings of resident TOCS were assessed to capture 4 domains: completeness, synopsis, foresight, and professionalism. In phase 1, 56 TOCS were used to modify the tool and improve reliability. In phase 2, 91 TOCS were used to examine validity. Analyses included Cronbach's alpha for internal structure, intraclass correlation and Cohen's kappa for interrater reliability, Pearson's correlation for relationships between variables, and 95% confidence interval of the mean for resident group comparisons. RESULTS: Cronbach's alpha was 0.52 for internal structure of the tool's subjective rating scale. Intraclass correlation for the subjective rating scale items ranged from 0.70 to 0.80. Cohen's kappa for most objective checklist items ranged from 0.43 to 1. Content completeness was significantly correlated with synopsis, foresight, and professionalism (Pearson's r ranged from 0.36 to 0.62, P values were <0.001). House staff senior residents scored higher (on average) than interns and rotating senior residents in synopsis and foresight. Also, house staff interns scored higher (on average) than rotating senior residents in professionalism. House staff senior residents scored higher (on average) than rotating senior residents in content completeness. CONCLUSIONS: We provide validity evidence to support using scores from the TOCS tool to assess higher-level transfer of care comprehension and communication by pediatric emergency department residents and to test interventions to improve TOCS.

Radiologic discrepancies in children with special healthcare needs in a pediatric emergency department.

BACKGROUND: After-hours radiologic interpretation by nonradiology attendings or resident radiologists introduces the risk of discrepancies. Clinical outcomes following radiologic discrepancies among pediatric emergency department (ED) patients are poorly described. In particular, children with special healthcare needs (CSHCN), have more opportunities for discrepancies and potential consequences than non- CSHCN. Our objective was to determine the rates and types of radiologic discrepancies, and to compare CSHCN to non-CSHCN. METHODS: From July 2014 to February 2015, all children who underwent a diagnostic imaging study at a free-standing children's ED were included. Data collected included radiologic studies - type and location - and clinical details - chief complaint and CSHCN type. Differences between preliminary reads and final pediatric radiology attending reads were defined as discrepancies, and categorized by clinical significance. Descriptive statistics, z-tests, and chi-square were used. RESULTS: Over 8months, 8310 visits (7462 unique patients) had radiologic studies (2620 CSHCN, 5690 non-CSHCN). A total of 198 (2.4%) radiologic discrepancies [56 (28.3%) CSHCN, 142 (71.7%) non-CSHCN] were found. Chief complaints for CSCHN were more often within the cardiac, pulmonary and neurologic systems (p<0.001 for each), whereas non-CSHCN presented with more trauma (p<0.001). The rates of discrepancies (CSHCN 2.1%, non- CSHCN 2.5%, p=0.3) and severity of clinical consequences (p=0.6) were not significantly different between CSHCN and non-CSHCN. CONCLUSION: Though the frequency and type of radiologic studies performed between CSHCN and non-CSHCN were different, we found no significant difference in the rate of radiologic discrepancies or the rate of clinically significant radiologic discrepancies.

Qualitative assessment of simulation-based training for pediatric trauma resuscitation.

BACKGROUND: Effective teamwork is critical in the trauma bay, although there is a lack of consensus related to optimal training for these skills. We implemented in situ trauma simulations with debriefing as a possible training methodology to improve team-oriented skills. METHODS: Focus groups were conducted with multidisciplinary clinicians who respond to trauma activations. The focus group questions were intended to elicit discussion on the clinicians' experiences during trauma activations and simulations with an emphasis on confidence, leadership, cooperation, communication, and opportunities for improvement. Thematic content analysis was conducted using Atlas.ti analytical software. RESULTS: Ten focus groups were held with a total of 55 clinicians. Qualitative analysis of focus group feedback revealed the following selected themes: characteristics of a strong leader during a trauma, factors impacting trauma team members' confidence, and effective communication as a key component during trauma response. Participants recommended continued simulations to enhance trauma team trust and efficiency. CONCLUSION: Clinicians responding to pediatric trauma resuscitations valued the practice they received during trauma simulations and supported the continuation of the simulations to improve trauma activation teamwork and communication. Findings will inform the development of future simulation-based training programs to improve teamwork, confidence, and communication between trauma team members.

The effect of multimedia replacing text in resident clinical decision-making assessment.

Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p2  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p2  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in CDMS, particularly in less experienced clinicians.

PEMNetwork: Barriers and Enablers to Collaboration and Multimedia Education in the Digital Age.

In January 2005, PEMFellows.com was created to unify fellows in pediatric emergency medicine. Since then, the website has expanded, contracted, and focused to adapt to the interests of the pediatric emergency medicine practitioner during the internet boom. This review details the innovation of the PEMNetwork, from the inception of the initial website and its evolution into a needs-based, user-directed educational hub. Barriers and enablers to success are detailed with unique examples from descriptive analysis and metrics of PEMNetwork web traffic as well as examples from other online medical communities and digital education websites.

Targeting Simulation-Based Assessment for the Pediatric Milestones: A Survey of Simulation Experts and Program Directors.

OBJECTIVE: To determine which of the 21 general pediatrics milestone subcompetencies are most difficult to assess using traditional methodologies and which are best suited to simulation-based assessment. METHODS: We surveyed 2 samples: pediatric simulation experts and pediatric program directors. Respondents were asked about current use of simulation for assessment and to select 5 of the 21 pediatric subcompetencies most difficult to assess using traditional methods and the 5 best suited to simulation-based assessment. Spearman rank correlation was used to determine a correlation between how the 2 samples ranked the subcompetencies. RESULTS: Forty-eight percent (29 of 60) simulation experts and 20% (115 of 571) program directors completed the survey. Few respondents reported using simulation for summative assessment. There are clear differences across the pediatric subcompetencies in perceived difficulty of assessment and suitability to simulation-based assessment. The 3 most difficult to assess subcompetencies were "recognize ambiguity," "demonstrate emotional insight," and "identify one's own strengths and deficiencies." The subcompetencies most suitable to assessment using simulation were "interprofessional teamwork," "clinical decision making," and "effective communication." Program directors and simulation experts had high agreement for both questions: difficult to assess (rho = 0.76, P < .001) and suitable to simulation-based assessment (rho = 0.94, P < .001). CONCLUSIONS: Several general pediatrics milestone subcompetencies were identified by pediatric simulation experts and pediatric program directors as difficult to assess using current methodologies and as amenable to simulation-based assessment. The pediatric simulation community should target development of simulation-based assessment tools to these areas.