Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations.

OBJECTIVE: To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps. METHODS: A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments. RESULTS: The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively. CONCLUSIONS: The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives. LEVEL OF EVIDENCE: 5 Laryngoscope, 133:3588-3601, 2023.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

A pilot study assessing clinic value in pediatric pharyngeal dysphagia: The OPPS/cost method.

OBJECTIVES/HYPOTHESIS: Given the costs of healthcare, capitation, and desires for quality improvement (QI), there is a need to better assess healthcare value. Time-driven activity-based costing and the Quadruple Aim have evaluated value by assessing health outcomes and provider experiences relative to costs. The proposed OPPS/Cost method expands on this to examine value for aerodigestive clinic treatment of pediatric persistent pharyngeal dysphagia: O + P1 + P2 + S/Cost (O = objective health [video-fluoroscopic swallow study results], P1 = patient/family experience [Consumer Assessment of Healthcare Providers and Systems], P2 = provider experience [Copenhagen Burnout Inventory {CBI}], S = subjective health [Feeding/Swallowing-Impact Survey], C = cost [time-driven activity-based costing]). STUDY DESIGN: Use of QI time data, surveys, and retrospective chart review for 56 patient encounters. METHODS: Staff interviews were used to develop process maps, and monetary values were assigned to activities. OPPS/Cost outcomes were normalized amongst variables, and composite values were calculated. Comparisons were made using a Student t test for pre- and postclinic relocation over a 14-month period. RESULTS: Time reductions were check-in (13 minutes/patient), rooming (21 minutes/patient), and providers (4 minutes/patient). Patient in-room wait time increased (4 minutes/patient). The CBI identified burnout as an area for improvement. OPPS/Cost composite values increased by 14%, with a 1.7% cost reduction, improvement in objective and subjective health outcomes of 47.4% (P < .05) and 7.3%, respectively, and stable patient/family experience. CONCLUSIONS: OPPS/Cost is feasible in an interdisciplinary clinic and helped evaluate value during a clinic relocation. The QI opportunities identified are indicative of the potential of OPPS/Cost. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1527-1532, 2019.

Standardizing Laryngeal Cleft Evaluations: Reliability of the Interarytenoid Assessment Protocol.

OBJECTIVE: While the Benjamin-Inglis classification system is widely used to categorize laryngeal clefts, it does not clearly differentiate a type 1 cleft from normal anatomy, and there is no widely accepted or validated protocol for systematically evaluating interarytenoid mucosal height. We sought to propose the interarytenoid assessment protocol as a method to standardize the description of the interarytenoid anatomy and to test its reliability. STUDY DESIGN: Retrospective review of endoscopic videos. SETTING: Pediatric academic center. SUBJECTS AND METHODS: The interarytenoid assessment protocol comprises 4 steps for evaluation of the interarytenoid region relative to known anatomic landmarks in the supraglottis, glottis, and subglottis. Thirty consecutively selected videos of the protocol were reviewed by 4 otolaryngologists. The raters were blinded to identifying information, and the video order was randomized for each review. We assessed protocol completion times and calculated Cohen's linear-weighted κ coefficient between blinded expert raters and with the operating surgeon to evaluate interrater/intrarater reliability. RESULTS: Median age was 4.9 years (59 months; range, 1 month to 20 years). Median completion time was 144 seconds. Interrater and intrarater reliability showed substantial agreement (interrater κ = 0.71 [95% confidence interval (CI), 0.55-0.87]; intrarater mean κ = 0.70 [95% CI, 0.59-0.92/rater 1, 0.47-0.85/rater 2]; P < .001). Comparing raters to the operating surgeon demonstrated substantial agreement (mean κ = 0.62; 95% CI, 0.31-0.79/rater 1, 0.48-0.89/rater 2; P < .001). CONCLUSION: The interarytenoid assessment protocol appears reliable in describing interarytenoid anatomy. Rapid completion times and substantial interrater/intrarater reliability were demonstrated. Incorporation of this protocol may provide important steps toward improved standardization in the anatomic description of the interarytenoid region in pediatric dysphagia.

The importance of technical skills assessment during an airway foreign body removal course.

PURPOSE: Surgical simulation has proven useful in training for high-acuity, low frequency events such as airway foreign body removal (AWFBR). Studies have supported the role of simulation to improve trainee confidence and technical proficiency, but rigorous methodology is often lacking. Through a pilot study, we sought to evaluate the feasibility and utility of two-view video capture for rigorous assessment of trainee skill in an educational course setting. METHODS: Participants were asked to perform 1) self-assessment surveys using 5- point Likert scale questions and 2) rigid bronchoscopy with AWFBR on intubation trainers, at the beginning and end of a multi-institution airway course. Video was collected from endoscopic and wide-angle body cameras. The videos were blinded and evaluated in random order by two expert reviewers using a 5-point pediatric airway endoscopy specific objective structured assessment of technical skills (OSATS) instrument. RESULTS: Fourteen trainees submitted pre- and post-course surveys, and eight of these also had complete video data. Faculty feedback indicated the importance of pre- and post-course AWFBR recordings for real-time trainee feedback and post-course curricular refinement. Survey data showed an increase in confidence for AWFBR from 2.0 to 3.3 (p = 0.05). Average OSATS scores increased from 1.84 to 2.58 but this did not reach significance (p = 0.51). Paired improvements in confidence exceeded improvements in OSATS scores (1.29 vs. 0.18, p = 0.058). CONCLUSIONS: Rigorously evaluated two-view video capture was feasible in an educational course setting. The course resulted in improvements in confidence to a greater degree than OSATS scores. This supports the importance of assessing course impact and refining curricula using all available data including objectively assessing technical skills.

Face, content, and construct validation of a low-cost, non-biologic, sinus surgery task trainer and knowledge-based curriculum.

BACKGROUND: The purpose of this study was to evaluate face and content validity of a low-cost, low-technology, non-biologic endoscopic sinus surgery (ESS) task trainer and knowledge-based curriculum followed by construct validation of the task trainer. METHODS: A sinus surgery task trainer and curriculum were developed. Attending otolaryngologists were surveyed regarding the utility of the task trainer and curriculum. A cross-sectional construct validation study was performed including medical students, residents, and attending otolaryngologists. Nine tasks were performed on the task trainer and graded using a global rating scale (GRS). Predictors of task trainer performance were evaluated, and spatial performance was measured. Regression analyses were performed to assess main associations. RESULTS: All attending physicians (n = 7) agreed that the task trainer accelerates the learning curve and incorporates essential ESS techniques and that the knowledge-based curriculum describes anatomical and technical knowledge germane to ESS. Twelve medical students, 9 otolaryngology residents, and 5 attending otolaryngologists completed task trainer testing. GRS score varied by level of training after adjusting for potential confounders (slope = 2.63; p = 0.001). There was evidence of an association between a history of video gaming (slope = 1.33; p = 0.077), sports experience (slope = 2.08; p = 0.033), and sinus surgery simulation (slope = 2.72; p = 0.023) with GRS score, although not statistically significant. CONCLUSION: This study demonstrated validity of a knowledge-based sinus surgery curriculum and low-cost, sinus task trainer supporting use in early training. Participants with prior video gaming, sports participation, and sinus surgery simulation experience perform better at baseline on the task trainer.

High-frequency sensorineural hearing loss in children.

OBJECTIVES/HYPOTHESIS: Determine the prevalence of high-frequency sensorineural hearing loss (HFSNHL) in our hearing loss population and a diagnostic algorithm for these patients. STUDY DESIGN: Retrospective case series. METHODS: We identified patients diagnosed with sensorineural hearing loss (SNHL) at our pediatric tertiary care institution from 1981 to 2010. Based on audiometric profiles, these patients were subdivided into those with a flat SNHL configuration and those with HFSNHL. Imaging and genetic testing data and data regarding age at diagnosis, laterality, and risk factors were obtained for both groups. Comparisons were then made between the two groups. RESULTS: Of 2,867 patients included in the study, 7.6% had HFSNHL. Age at diagnosis was significantly higher in HFSNHL patients (8.3 years vs. 6.1 years; P < .0001). These patients also had a significantly higher proportion of unilateral versus bilateral loss (49.1% vs. 26.1%; P < .0001); unilateral losses were also less severe. Genetic testing showed no significant difference between groups in the proportion of patients tested or in those who tested positive. Similarly, imaging data revealed no difference in the proportion of patients tested in the two groups; however, overall diagnostic yield was significantly higher in flat SNHL patients (29.5% vs.17.3; P = .02). CONCLUSIONS: The positive predictive value of simple genetic testing is similar to that of imaging studies. However, given cost differences between genetic testing and imaging, it is prudent to perform genetic testing as the initial diagnostic test. Determination of whether high-throughput, multigene diagnostic platforms offer an added benefit in the evaluation of children requires further study. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1236-1240, 2016.

Blinded evaluation of interrater reliability of an operative competency assessment tool for direct laryngoscopy and rigid bronchoscopy.

OBJECTIVES To confirm interrater reliability using blinded evaluation of a skills-assessment instrument to assess the surgical performance of resident and fellow trainees performing pediatric direct laryngoscopy and rigid bronchoscopy in simulated models. DESIGN Prospective, paired, blinded observational validation study. SUBJECTS Paired observers from multiple institutions simultaneously evaluated residents and fellows who were performing surgery in an animal laboratory or using high-fidelity manikins. The evaluators had no previous affiliation with the residents and fellows and did not know their year of training. INTERVENTIONS One- and 2-page versions of an objective structured assessment of technical skills (OSATS) assessment instrument composed of global and a task-specific surgical items were used to evaluate surgical performance. RESULTS Fifty-two evaluations were completed by 17 attending evaluators. The instrument agreement for the 2-page assessment was 71.4% when measured as a binary variable (ie, competent vs not competent) (κ = 0.38; P = .08). Evaluation as a continuous variable revealed a 42.9% percentage agreement (κ = 0.18; P = .14). The intraclass correlation was 0.53, considered substantial/good interrater reliability (69% reliable). For the 1-page instrument, agreement was 77.4% when measured as a binary variable (κ = 0.53, P = .0015). Agreement when evaluated as a continuous measure was 71.0% (κ = 0.54, P < .001). The intraclass correlation was 0.73, considered high interrater reliability (85% reliable). CONCLUSIONS The OSATS assessment instrument is an effective tool for evaluating surgical performance among trainees with acceptable interrater reliability in a simulator setting. Reliability was good for both the 1- and 2-page OSATS checklists, and both serve as excellent tools to provide immediate formative feedback on operational competency.