A Mixed Methods Needs Assessment for a Debriefing Intervention Following Critical Cases.

OBJECTIVE: The emergency department (ED) is a demanding environment, and critical events have been identified as contributors to stress. Debriefing is a possible intervention for staff, but there is little information regarding formulation and implementation. A needs assessment was conducted to describe the emotions of pediatric ED (PED) staff following critical events and assess opinions regarding debriefing. METHOD: This mixed methods study used convergent design for triangulation. After critical cases, PED staff members were given the Peritraumatic Distress Inventory (PDI). Additionally, a questionnaire with 2 open-ended questions on debriefing was administered. Themes were extracted from the questionnaire using directed content analysis. RESULTS: A total of 719 responses were collected for 142 critical cases. Physical reactions were often endorsed in the PDI, and these reactions were mirrored in the qualitative data, which included physiological responses such as stress, adrenaline high, anxiety, fatigue, and overwhelm. Helplessness and grief were 2 of the emotional PDI items frequently endorsed, which were reflected in the qualitative strand by themes such as helplessness, sadness, disheartenment, and regret. There was considerable variability between critical cases such that not every critical case elicited a desire for a debrief. CONCLUSIONS: PED staff report measurable levels of stress after critical patient cases that warrant follow-up. Formal debriefing immediately after critical patient cases with specific caveats may be valuable for the reduction of stress. Any formal debriefing program will need to balance various goals with attention to the session length, setting, and timing.

Adolescent and young adult stress and coping during COVID-19: the utility of a pediatric emergency department screener.

BACKGROUND: COVID-19 altered lives, especially adolescents and young adults who lost their emotional and social support systems and may be suffering. OBJECTIVE: In response to the coronavirus pandemic, a questionnaire was created and administered to Pediatric Emergency Department (PED) patients in order to identify psychosocial stress and coping abilities. METHODS: A 12-question (yes/no) quality improvement (QI) paper-based questionnaire was administered by PED providers to assess psychosocial stress and coping among patients 12 years and greater who presented to the PED at a tertiary Children's Hospital, March-September 2020. Questions were asked/recorded to determine rates of distress and provide social work intervention, if needed. Analysis-Chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Among 1261 PED patients who participated in the study, the mean age was 15.4 years (SD = 2.4), (58% female, 41.5% male, 0.6% missing data). We identified 611 patients (48.5%) who admitted to feeling scared about contracting the disease, 876 patients (69.5%) who were concerned about the health of their families, and 229 patients (18.2%) who screened positive for food insecurity. In addition, 596 patients (47.3%) felt anxiety, 333 patients (26.4%) felt depressed, and 13 patients (1%) admitted to having suicidal ideation because of COVID-19. The majority of patients, 1165 (92.4%), felt supported during the pandemic. Social work was consulted for 235 (18.6%) of patients participating. CONCLUSIONS: While patients typically present to PEDs for a somatic complaint, screening their psychosocial and emotional states may reveal underlying mental health concerns that require intervention and at times, assistance from social workers.

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.

Factors influencing termination of resuscitation in children: a qualitative analysis.

BACKGROUND: Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians. METHODS: A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors. RESULTS: Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept. CONCLUSION: Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

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.

Use of Audiobooks as an Environmental Distractor to Decrease State Anxiety in Children Waiting in the Pediatric Emergency Department: A Pilot and Feasibility Study.

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED. Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre-post intervention changes in fear and state anxiety. Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's d z = 0.22-0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content "a lot" as well as enjoyed listening to the audiobook "a lot." Without prompting, 15% of participants requested to listen to an additional audiobook. Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

Pediatric Online Disaster Preparedness Training for Medical and Non-Medical Personnel: A Multi-Level Modeling Analysis.

IntroductionTerrorism and natural catastrophes have made disaster preparedness a critical issue. Despite the documented vulnerabilities of children during and following disasters, gaps remain in health care systems regarding pediatric disaster preparedness. This research study examined changes in knowledge acquisition of pediatric disaster preparedness among medical and non-medical personnel at a children's hospital who completed an online training course of five modules: planning, triage, age-specific care, disaster management, and hospital emergency code response. METHODS: A multi-disciplinary team within the Pediatric Disaster Resource and Training Center at Children's Hospital Los Angeles (Los Angeles, California USA) developed an online training course. Available archival course data from July 2009 to August 2012 were analyzed through linear growth curve multi-level modeling, with module total score as the outcome (0 to 100 points), attempt as the Level 1 variable (any module could be repeated), role in the hospital (medical or non-medical) as the Level 2 variable, and attempt by role as the cross-level effect. RESULTS: A total of 44,115 module attempts by 5,773 course participants (3,686 medical personnel and 2,087 non-medical personnel) were analyzed. The average module total score upon first attempt across all participants ranged from 60.28 to 80.11 points, and participants significantly varied in how they initially scored. On average in the planning, triage, and age-specific care modules: total scores significantly increased per attempt across all participants (average rate of change ranged from 0.59 to 1.84 points) and medical personnel had higher total scores initially and through additional attempts (average difference ranged from 13.25 to 16.24 points). Cross-level effects were significant in the disaster management and hospital emergency code response modules: on average, total scores were initially lower among non-medical personnel compared to medical personnel, but non-medical personnel increased their total scores per attempt by 3.77 points in the disaster management module and 6.40 points in the hospital emergency code response module, while medical personnel did not improve their total scores through additional attempts. CONCLUSION: Medical and non-medical hospital personnel alike can acquire knowledge of pediatric disaster preparedness. Key content can be reinforced or improved through successive training in an online course. PhamPK, BeharSM, BergBM, UppermanJS, NagerAL. Pediatric online disaster preparedness training for medical and non-medical personnel: a multi-level modeling analysis Prehosp Disaster Med. 2018;33(4):349-354.

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.

Bacteremia in nonneutropenic pediatric oncology patients with central venous catheters in the ED.

OBJECTIVE: To examine clinical characteristics associated with bacteremia in febrile nonneutropenic pediatric oncology patients with central venous catheters (CVCs) in the emergency department (ED). BACKGROUND: Fever is the primary reason pediatric oncology patients present to the ED. The literature states that 0.9% to 39% of febrile nonneutropenic oncology patients are bacteremic, yet few studies have investigated infectious risk factors in this population. METHODS: This was a retrospective cohort study in a pediatric ED, reviewing medical records from 2002 to 2014. Inclusion criteria were patients with cancer, temperature at least 38°C, presence of a CVC, absolute neutrophil count greater than 500 cells/µL, and age less than 22 years. Exclusion criteria were repeat ED visits within 72 hours, bloodwork results not reported by the laboratory, and patients without oncologic history documented at the study hospital. The primary outcome measure is a positive blood culture (+BC). Other variables include age, sex, CVC type, cancer diagnosis, absolute neutrophil count, vital signs, upper respiratory infection (URI) symptoms, and amount of intravenous (IV) normal saline (NS) administered in the ED. Data were analyzed using descriptive statistics and a multiple logistic regression model. RESULTS: A total of 1322 ED visits were sampled, with 534 enrolled, and 39 visits had +BC (7.3%). Variables associated with an increased risk of +BC included the following: absence of URI symptoms (odds ratio [OR], 2.30; 95% CI, 1.13-4.69), neuroblastoma (OR, 3.65; 95% CI, 1.47-9.09), "other" cancer diagnosis (OR, 4.56; 95% CI, 1.93-10.76), tunneled externalized CVC (OR, 5.04; 95% CI, 2.25-11.28), and receiving at least 20 mL/kg IV NS (OR, 2.34; 95% CI, 1.2-4.55). The results of a multiple logistic regression model also showed these variables to be associated with +BC. CONCLUSION: The absence of URI symptoms, presence of an externalized CVC, neuroblastoma or other cancer diagnosis, and receiving at least 20 mL/kg IV NS in the ED are associated with increased risk of bacteremia in nonneutropenic pediatric oncology patients with a CVC.

Mental Health Screening Among Adolescents and Young Adults in the Emergency Department.

OBJECTIVE: To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints. METHODS: An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, χ test, Mann-Whitney U test, and Spearman correlation. RESULTS: Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered "yes" to at least 1 ED-DRS item; asymptomatic patients answered "no" to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation. CONCLUSIONS: Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS.

Caregiver Expectations and Satisfaction of Urgent Care in a Pediatric Emergency Department.

Health care delivery expectations that may affect patient and caregiver satisfaction are not clearly understood. This study examined caregiver expectations and satisfaction with urgent care in a pediatric emergency department. Of 201 caregivers surveyed, we found that caregivers have specific expectations regarding clinical care of their child in terms of radiographic imaging, blood testing, antibiotics, pain management, and subspecialty consultation. Caregivers were generally less dissatisfied with the actual care provided than the urgent care physicians expected.

An Analysis of Intravenous Catheter Placement Among Patients in a Pediatric Emergency Department.

OBJECTIVES: Pediatric emergency departments (PED) are overcrowded and at times inefficient with malaligned resources, especially regarding the use of intravenous (IV) catheters which are placed frequently, yet may be underused. This study seeks to determine which pediatric patients are more likely to need IV access in a PED. METHODS: This retrospective study examined patients 3 days to 21 years seen in a tertiary PED from January 1, 2013, to February 28, 2013, who were triaged using the Emergency Severity Index, levels 1 to 3. Extracted data included age, chief complaints, chronic medical conditions, final diagnoses, evidence of venipuncture, and IV placement and usage. Patients were excluded if they entered the PED with an IV or central venous catheter, were older than 21 years, or had charts with missing data. RESULTS: Four thousand three hundred twenty-two patients were initially evaluated, and 122 patients were excluded. Mean age of the patients was 6.2 years (SD = 5.65), most common triage was level 3 (urgent), and the majority of patients (n = 2898, 69.0%) did not have a chronic medical condition. Five hundred forty-five (13%) had IVs placed, and of those, 152 (27.9%) had IVs placed and not used. Patients triaged as critical or emergent, patients older than 10 years, and those with a gastrointestinal chief complaint and chronic medical conditions involving hematology, oncology/immunology, or endocrinology were most likely to have an IV placed and used. CONCLUSIONS: Patients with higher acuities, specified systemic complaints, certain chronic medical conditions, and patients older than 10 years are more likely to need an IV.

March of the Living, a Holocaust Educational Tour: An Assessment of Anxiety and Depression.

March of the Living (MOTL) is a 2-week international educational tour for high school seniors to learn about the Holocaust by visiting concentration/deaths camps and other Jewish historical sites in Poland, culminating in a week-long excursion in Israel. Although the trip is primarily educational, there is recent research evidence to suggest that attendees may suffer from a variety of mental health sequelae. To determine symptoms of anxiety and depression, 196 Los Angeles delegation participants voluntarily completed the State-Trait Anxiety Inventory, composed of a trait anxiety scale (i.e., STAI-T) and a state anxiety scale (i.e., STAI-S), and the Center for Epidemiologic Studies Depression Scale (CES-D). Pre-MOTL, students completed an initial background questionnaire along with the STAI-T, STAI-S, and the CES-D. At end-Poland and end-Israel, the STAI-S and CES-D were administered again. Results demonstrated that depression scores increased during end-Poland and returned to baseline; however, anxiety scores mildly increased end-Poland and rose slightly more and persisted through end-Israel.

Effects of acupuncture on pain and inflammation in pediatric emergency department patients with acute appendicitis: a pilot study.

OBJECTIVE: Acupuncture has been shown to treat various medical conditions, including acute and chronic pain, and there is limited evidence that acupuncture produces anti-inflammatory effects. This pilot study evaluated the use of acupuncture to treat pain and determine if acupuncture can reduce the inflammatory response in pediatric patients diagnosed with acute appendicitis. DESIGN: This pilot study used convenience sampling and was conducted in the Pediatric Emergency Department (PED) of an urban tertiary care children's hospital. Patients conventionally evaluated and definitively diagnosed with appendicitis were eligible to voluntarily participate. INTERVENTION: The diagnostic homogeneity of the target population allowed for a standardized intervention protocol. A licensed acupuncturist performed a specific form of Japanese acupuncture known as the Kiiko Matsumoto Style on all study patients. OUTCOME MEASURES: Subjective pain was assessed immediately before the intervention and 20 minutes postintervention, using 3 measures: Faces Pain Scale-Revised (FPS-R), colored analog scale (CAS), and visual analog scale (VAS). Evidence of inflammation was assessed using two biomarkers: white blood cell (WBC) count and C-reactive protein (CRP). WBC and CRP were drawn and recorded 3 times: before the intervention, 2 minutes before removal of needles, and 30 minutes after needling. RESULTS: Six Latino/Hispanic patients (4 males, 2 females, median age=15 years) with no previous acupuncture experience participated in the study. Median pre/postacupuncture pain scores were as follows: FPS-R, 5 vs. 4; CAS, 6.1 vs. 4.8; VAS, 46 vs. 32. Median WBC (10(3)/µL) and CRP (mg/dL) across time were as follows: WBC, 13.2, 11.8, and 11.4; CRP, 4.5, 4.9, and 5.1. Median acupuncture duration was 28.5 minutes (range 22-32) and no complications were observed. CONCLUSIONS: Pilot data suggest that acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation as measured by WBC. Acupuncture may be a useful nonpharmacological PED intervention for treating patients with acute appendicitis pain.

Reducing anxiety in the pediatric emergency department: a comparative trial.

BACKGROUND: Anxiety among patients in a pediatric emergency department (PED) can be significant, but often goes unaddressed. OBJECTIVE: Our aim was to determine whether exposure to Child Life (CL) or hospital clowning (HC) can reduce anxiety in children presenting to a PED. METHODS: Patients were randomized to CL, HC, or control and assessed upon entry to examination room (T1), before physician arrival (T2), and during physician examination (T3), using the modified Yale Preoperative Anxiety Scale (m-YPAS). CL and HC interventions occurred for 5 to 10 min before physician entry. Effects were analyzed using mixed analysis of variance. RESULTS: m-YPAS scores ranged from 23 to 59, with a higher score indicating increased anxiety. Mixed analysis of variance on the study sample (n = 113) showed a significant interaction between groups (CL, HC, control) and time (p = 0.02). Additional analyses indicated effect of group only at T2 (CL: mean = 23.8; 95% confidence interval [CI] 23.2-24.5; HC: mean 25.2; 95% CI 24.2-26.2; control: mean = 26.1; 95% CI 24.2-27.9; p = .02). Subanalysis of patients with T1 m-YPAS score ≥ 28 (n = 56) showed a significant interaction between group and time (p = 0.01). Additional analysis showed effect of group only at T2 (CL: mean 24.4; 95% CI 23.3-25.6; HC: mean 27.0; 95% CI 25.2-28.7; control: mean 29.2; 95% CI 25.6-32.7; p = 0.003). CONCLUSIONS: CL services can reduce state anxiety for patients presenting to a PED with heightened anxiety at baseline. This reduction occurred immediately after CL intervention, but was not observed in patients exposed to HC or during physician examination.

Pediatric advance directives: parents' knowledge, experience, and preferences.

OBJECTIVES: To explore parents' and caregivers' experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS: We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child's past and current health status, and family demographics. RESULTS: Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS: The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Competency-based pediatric disaster training.

OBJECTIVE: To assess whether participation in a competency-based pediatric disaster educational curriculum increases participants' knowledge of how to manage pediatric disaster victims. DESIGN: Pretest/post-test intervention study. SETTING: Large, urban, academic tertiary hospital. PATIENTS/PARTICIPANTS: Three hundred twenty-six clinical and nonclinical healthcare employees. MAIN OUTCOME MEASURE: Pre-educational and posteducational intervention scores on a 30-item pediatric disaster test. RESULTS: Participants without prior pediatric disaster training had significant improvements between pre-educational and posteducational intervention test scores (p < 0.0001). CONCLUSIONS: Our competency-based pediatric disaster educational intervention improved the knowledge of most attendees, the majority of whom infrequently care for pediatric patients. This set of pediatric disaster competencies can be used in future formulation of a standardized curriculum.

Traditional nurse triage vs physician telepresence in a pediatric ED.

OBJECTIVES: The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP). METHODS: This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children's hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. RESULTS: Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences. CONCLUSIONS: Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.