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

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

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

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

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

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

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

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

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

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

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

Examining trust between supervisors and trainees in the pediatric emergency department.

Objective: Lack of trust between supervisors and trainees can have harmful consequences. Trust has been examined between physicians, patients, and staff in multiple settings but has not been examined in a bidirectional manner in the pediatric emergency department (PED). Debra Meyerson in 1996 discussed the theory of swift trust, a type of trust that develops quickly between temporary groups through reliance on categories. Meyerson describes categories as groups unified by social identities such as gender or profession. We explored the applicability of swift trust in the relationship between supervisors and trainees in the PED. Methods: This multimethods study used qualitative interviews and the validated interpersonal mistrust trust measure (IMTM) to assess baseline trusting style. PED attendings from a single institution and residents from various training levels, specialties, and institutions rotating through the same PED were sampled until thematic saturation was reached. Interviews were analyzed using directed content analysis. IMTM scores were triangulated with interviewee's reported trusting styles. Results: Seventeen PED attendings and 16 residents participated. Residents and attendings emphasized different factors that influence trust. Common factors across groups included affect, the need for vulnerability, and appropriate communication. Most described reliance on certain categories (level of training, specialty, etc.) when making trusting decisions. Categories such as gender and race were noted to be unimportant when making trusting decisions about others, although some participants believed these attributes played into decisions made by others. Quantitative data from the IMTM supported qualitative conclusions regarding trusting style. Conclusions: The trusting relationship between supervisors and trainees in the PED dovetails with the swift trust theory. Common factors that influence trust reveal entry points for attendings and residents to improve trust and ultimately prevent negative patient outcomes. Future studies may examine how reliance on categories influences an individual's trust in their colleagues.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation.

BACKGROUND: The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit. METHODS: This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework. RESULTS: Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized. CONCLUSIONS: Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

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

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

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

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

Quantifying Simulated Contamination Deposition on Healthcare Providers Using Image Analysis.

INTRODUCTION: Simulation-based research has played an important role in improving care for communicable diseases. Unfortunately, few studies have attempted to quantify the level of contamination in these simulation activities. We aim to assess the feasibility and provide validity evidence for using integrated density values and area of contamination (AOC) to differentiate various levels of simulated contamination. METHODS: An increasing number of simulated contamination spots using fluorescent marker were applied on a manikin chest to simulate a contaminated healthcare provider. An ultraviolet light was used to illuminate the manikin to highlight the simulated contamination. Images of increasing contamination levels were captured using a camera with different exposure settings. Image processing software was used to measure 2 outcomes: (1) natural logarithm of integrated density; and (2) AOC. Mixed-effects linear regression models were used to assess the effect of contamination levels and exposure settings on both outcome measures. A standardized "proof-of-concept" exercise was set up to calibrate and formalize the process for human subjects. RESULTS: A total of 140 images were included in the analyses. Dose-response relationships were observed between contamination levels and both outcome measures. For each increment in the number of contaminated simulation spots (ie, simulated contaminated area increased by 38.5 mm 2 ), on average, log-integrated density increased by 0.009 (95% confidence interval, 0.006-0.012; P < 0.001) and measured AOC increased by 37.8 mm 2 (95% confidence interval, 36.7-38.8 mm 2 ; P < 0.001), which is very close to actual value (38.5 mm 2 ). The "proof-of-concept" demonstration further verified results. CONCLUSIONS: Integrated density and AOC measured by image processing can differentiate various levels of simulated, fluorescent contamination. The AOC measured highly agrees with the actual value. This method should be optimized and used in the future research to detect simulated contamination deposited on healthcare providers.

Mental Health Revisits at US Pediatric Emergency Departments.

Importance: Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective: To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants: In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures: Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures: The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results: There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance: Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

The Effect of a Plastic Barrier Drape on Resuscitation Performance and Provider Contamination: A Randomized Controlled Simulation-Based Pilot Trial.

BACKGROUND: Patient barriers to protect health care workers from COVID-19 exposure have been studied for airway management. Few are tested for cardiopulmonary resuscitation (CPR). We sought to determine whether a plastic drape barrier affects resuscitation performance and contamination risks for a simulated cardiopulmonary arrest scenario. METHODS: This pilot trial randomized in-hospital resuscitation teams of 4 to 6 participants to a plastic drape or without a drape in an in situ cardiopulmonary arrest simulation. The mannequin's airway emanated simulated virus particles (GloGerm, Moab, UT), detectable through UV light. Primary outcomes included airway management and CPR quality measures. Secondary outcomes included visible contamination on personal protective equipment (PPE). We used the Non-Technical Skills (NO-TECHS) instrument to measure perceived team performance and the NASA Task Load Index (NASA-TLX) to measure individual workload. Outcome variables were analyzed using an analysis of covariance (ANCOVA) with participant number as a covariate. RESULTS: Seven teams were allocated to the intervention (plastic drape) group and 7 to the control. Intubation and ventilation performance (η 2 = 0.09, P > 0.3) and chest compression quality (η 2 = 0.03-0.19, P > 0.14) were not affected by the plastic drape. However, mean contaminated PPE per person decreased with the drape (2.8 ± 0.3 vs. 3.7 ± 0.3, partial η 2 = 0.29, P = 0.05). No differences in perceived workload nor team performance were noted ( P > 0.09). CONCLUSIONS: In this pilot study, the use of a plastic drape barrier seems not to affect resuscitation performance on simulated cardiopulmonary arrest but decreases health care worker contamination risk. Further implementation trials could characterize the true risk reduction and any effect on resuscitation outcomes.

Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter.

Introduction: A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. Methods: This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Results: Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Conclusions: The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.

Advances in Pediatric Surgery Simulation-Based Training.

Pediatric surgery is the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases. The early history of the specialty followed the classic "see one, do one, teach one" philosophy of training but has since evolved to modern methods including simulation-based training (SBT). Current trainees in pediatric surgery face numerous challenges, such as the decreasing incidence of congenital disease and reduced work hours. SBT consists of several modalities that together assist in the acquisition of technical skills and improve performance in the operating room. SBT has evolved to incorporate simulator models and video gaming technology, in parallel with the development of simulation in other surgical and non-surgical pediatric fields. SBT has advanced to a level of sophistication that means that it can improve the skills of not only pediatric surgery trainees but also practicing attending surgeons. In this review, we will discuss the history of pediatric surgery, simulation in pediatric surgery training, and the potential direction of pediatric surgical simulation training in the future.

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation.

Background: Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings. Methods: We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking. Results: Small groups (n = 121) and survey ranking (n = 54) were used with distance, remote, and telesimulation as leading terms. Each was favored by a third of the participants without consensus. Conclusion: This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of distance, remote and telesimulation is preferred.