Selection and Recruitment Strategies among Competitive Pediatric Training Programs and the Impact of Diversity.

OBJECTIVE: Aspects of the written application, interview and ranking may negatively impact recruitment of underrepresented in medicine (URiM) applicants. Our objectives were to explore knowledge, attitudes, and perceptions of pediatric faculty who assess potential trainees and how diversity impacts these assessments. METHODS: We performed qualitative interviews of 20 geographically diverse faculty at large pediatric residencies and fellowships. We analyzed data using the constant comparative method to develop themes. RESULTS: Four main themes emerged. CONCLUSIONS: We describe ways in which bias infiltrates recruitment and strategies to promote diversity. Many strategies are variably implemented and the impact on workforce diversity in pediatric training programs remains unknown.

Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach.

BACKGROUND: Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS: A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS: All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS: Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.

Management of the Difficult Airway.

ABSTRACT: Airway management is a fundamental component of care during resuscitation of critically ill and injured children. In addition to predicted anatomic and physiologic differences in children compared with adults, certain conditions can predict potential difficulty during pediatric airway management. This review presents approaches to identifying pediatric patients in whom airway management is more likely to be difficult, and discusses strategies to address such challenges. These strategies include optimization of effective bag-mask ventilation, alternative approaches to laryngoscopy, use of adjunct airway devices, modifications to rapid sequence intubation, and performance of surgical airways in children. The importance of considering systems of care in preparing for potentially difficult pediatric airways is also discussed.

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.

STUDY OBJECTIVE: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

Formative Assessments Promote Procedural Learning and Engagement for Senior Pediatric Residents on Rotation in the Pediatric Emergency Department.

Introduction: Procedural training is a universal concern amongst pediatric residents and their teachers. We developed and implemented formative assessments to generate direct and indirect procedural feedback. We analyzed changes in residents' perceived procedural knowledge, skills, confidence, and entrustment. Methods: Senior pediatric residents rotating in the pediatric emergency department participated in video-recorded formative assessments of informed consent OSCEs and simulated toddler forehead laceration repair and infant lumbar puncture. Residents reflected on their perceived procedural knowledge, skills, confidence, and entrustment through Likert and entrustment scales. Secondary outcomes of formative assessment completion rates and proportions of procedures performed by pediatric residents tracked feasibility and potential clinical impact, respectively. Results: Including the pilot period, 89% of residents (31 out of 35) received direct and indirect procedural feedback. Perceived composite competency and entrustment improved for laceration repair (competency: from 3.1 to 3.9, p < .001; entrustment: from 4.0 to 5.1, p < .001) and lumbar puncture (competency: from 3.5 to 4.0, p < .001; entrustment: from 4.6 to 5.6, p = .001). We observed an increase in the proportion of clinical laceration repairs (11% [97 out of 885] vs. 23% [218 out of 946], p < .001) and lumbar punctures (23% [12 out of 54] vs. 41% [21 out of 52], p = .05) performed by pediatric residents. Discussion: Integrating feasible procedural formative assessments into the pediatric emergency department rotation had a positive impact on senior pediatric residents' perceptions of their procedural knowledge, skills, confidence, and entrustment and was associated with increased procedural engagement.

A Workplace Procedure Training Cart to Augment Pediatric Resident Procedural Learning.

OBJECTIVE: Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients. METHODS: Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention. RESULTS: From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents. CONCLUSIONS: A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.

Can Behavior-Based Interviews Reduce Bias in Fellowship Applicant Assessment?

PURPOSE: Components of trainee applications may introduce bias based on race or gender. Behavior-based interviews (BBIs) rely on structured questions to elicit applicants' past experiences to predict future behavior. Our objective was to implement BBIs in one fellowship program and compare applicant assessment by race and gender when using a standardized assessment tool versus a BBI-based tool. METHODS: In 2019 and 2020, we developed BBIs and BBI-specific assessments; 6 of 15 faculty were trained in this interview method. Applicants completed 6 interviews with either a BBI or unstructured format. All faculty completed a standardized assessment on applicants. BBI faculty also completed a BBI-specific assessment. Normalized average scores were calculated and used to rank applicants into quartiles. Race was categorized into White, underrepresented minorities (URMs; Black and Hispanics), and non-URMs (all others). Faculty and applicants were surveyed about BBIs. RESULTS: Seventy-five applicants were interviewed. Significant differences were found in standardized assessment scores (White 1.01 +/- 0.09, non-URM 1.02 +/- 0.08, URM .94 +/- 0.07; P = .02) and quartiles by race (P = .05), but not for BBI scores (White 0.98 +/- 0.09, non-URM 1.03 +/- 0.09, URM 1.02 +/- 0.1; P = .18) or quartiles by race (P = .17). There were no significant differences in score or quartile by gender for either tool. The majority of faculty and applicant survey respondents commented positively about BBIs. CONCLUSION: BBIs were successfully implemented and generally reviewed positively by faculty and applicants. BBIs reduced racial differences in applicant assessments. Applicant assessment may benefit from structured tools to mitigate potential biases.

A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting.

The primary aim of this quality improvement initiative was to decrease the use of computerized tomography (CT) in the evaluation of pediatric appendicitis in a community general emergency department (GED) system by 50% (from 32% to 16%) in 1 year. METHODS: Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and "over-transfer" rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. RESULTS: The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children's hospital rate of 23.5%, and an "over-transfer" rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. CONCLUSIONS: Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.

Pediatric Emergency Medicine ECHO (Extension for Community Health Care Outcomes): Cultivating Connections to Improve Pediatric Emergency Care.

BACKGROUND: An Extension for Community Health Care Outcomes (ECHO) provides the opportunity for specialists at academic medical centers (AMCs) and frontline community generalists to engage in bidirectional learning. Specialists provide generalists with the current best evidence, and generalists share the local challenges applying this evidence to their practice. All ECHO participants strategize how to navigate these challenges together. Pediatric emergency medicine (PEM) may benefit from this knowledge translation strategy because most children seek emergency care from generalists in community emergency departments (CEDs) where variations in care between the AMC and the CED have been reported. METHODS: Our objective was to use ECHO to cultivate a PEM community of practice that facilitated knowledge translation and generated future CED pediatric improvement initiatives. As such, we developed, implemented, and evaluated a PEM ECHO. We conducted general and targeted needs assessments to inform our curriculum and formatted the sessions to generate bidirectional learning. A postparticipation evaluation collected self-reported perceptions about knowledge translation, planned provider practice changes, and perceptions of the formation of a community of practice. Additionally, we solicited information on the implementation of any pediatric improvement activities attributed to the PEM ECHO. RESULTS: Thirteen 1-hour sessions covered the chosen PEM topics. Participants represented diverse CEDs, with varied experience and roles in caring for children. All respondents (13/13) appreciated the ECHO learning format, reported improved PEM knowledge, and perceived the cultivation of a community of practice. Nine (85%) individuals attributed implementation of new pediatric improvement activities to the PEM ECHO. CONCLUSIONS: Our PEM ECHO was associated with improved perceptions of PEM knowledge, cultivated a community of practice, and facilitated the implementation of CED pediatric improvement activities. The PEM ECHO's bidirectional learning format generated new initiatives and partnerships aiming to improve the emergency care of children.

"PEM Pals"-Cultivating a Learning Community During the Pandemic.

OBJECTIVES: The current pandemic has pushed medical educators to rethink traditional learning constructs as residents are experiencing fewer patient contacts in the pediatric emergency department (PED). Especially for those bound for a career in pediatric emergency medicine (PEM), we designed a curriculum to proactively address this emerging learning gap, incorporating a wellness "check-in" at the beginning of each session. The objective of this report is to share the themes of this wellness check-ins with those engaged in pediatric emergency medicine education and mentorship. Additionally, we share our curricular approach as we plan to continue PEM Pals after the pandemic restrictions are lifted. METHODS: "PEM Pals" is a twice-weekly video conference meeting made up of pediatric residents with an expressed interest in PEM and those residents currently on rotation in the pediatric emergency department. Following a flipped classroom model, participants complete a presession learning activity and then core PEM topics are covered through literature review, case discussions, and telesimulations. Each meeting begins with a wellness "check-in." Themes generated from these check-ins were member checked by our core learning contingent. RESULTS: Nine residents make up our core learning contingent and we have had 11 "PEM Pals" sessions since March 2020. Three themes emerged from the wellness check-ins. The first was each postgraduate year's unique concern over professional transitions. The second was a pervasive sense of guilt. And the third was a grave concern about their ability to support and be supported from their personal communities. CONCLUSIONS: The goal of our curriculum was to supplement an anticipated knowledge gap. Through use of a wellness "check-in," we elicited important themes for PEM educational leaders to consider as they mentor pediatric residents toward a career in PEM during the pandemic.

Simulated airway drills as a tool to measure and guide improvements in endotracheal intubation preparation in the paediatric emergency department.

Introduction: Emergent paediatric intubation is an infrequent but high-stakes procedure in the paediatric emergency department (PED). Successful intubations depend on efficient and accurate preparation. The aim of this study was to use airway drills (brief in-situ simulations) to identify gaps in our paediatric endotracheal intubation preparation process, to improve on our process and to demonstrate sustainability of these improvements over time in a new staff cohort. Method: This was a single-centre, simulation-based improvement study. Baseline simulated airway drills were used to identify barriers in our airway preparation process. Drills were scored for time and accuracy on an iteratively developed 16-item rubric. Interventions were identified and their impact was measured using simulated airway drills. Statistical analysis was performed using unpaired t-tests between the three data collection periods. Results: Twenty-five simulated airway drills identified gaps in our airway preparation process and served as our baseline performance. The main problem identified was that staff members had difficulty locating essential airway equipment. Therefore, we optimised and implemented a weight-based airway cart. We demonstrated significant improvement and sustainability in the accuracy of obtaining essential airway equipment from baseline to postintervention (62% vs 74%; p=0.014), and postintervention to sustainability periods (74% vs 77%; p=0.573). Similarly, we decreased and sustained the time (in seconds) required to prepare for a paediatric intubation from baseline to postintervention (173 vs 109; p=0.001) and postintervention to sustainability (109 vs 103; p=0.576). Conclusions: Simulated airway drills can be used as a tool to identify process gaps, measure and improve paediatric intubation readiness.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program.

OBJECTIVES: Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. METHODS: We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. RESULTS: Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. CONCLUSIONS: Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

Advanced Pediatric Emergency Airway Management: A Multimodality Curriculum Addressing a Rare but Critical Procedure.

Introduction: Advanced airway management in pediatrics is a rare, high stakes skillset. Developing proficiency in these skills is paramount, albeit challenging. Providers require innovative approaches to address initial training and maintenance of procedural competency. To address this, we developed a multimodality curriculum. Methods: Through an interactive problem-based learning session utilizing real intubation videos, hands-on skill stations, and two simulation-based scenarios, participants advanced through educational objectives towards the goal of improving perceived comfort, knowledge, skills, and attitudes in emergency pediatric advanced airway management. Content was developed by integrating varied learning modalities under the learn, see, practice, prove, do, maintain construct. Please note the specialized equipment needed for this curriculum included pediatric airway trainers and a video laryngoscope. Results: We have conducted the curriculum in its entirety four times, reaching 131 interdisciplinary participants. Forty-nine physicians of varying training backgrounds and clinical working environments completed postparticipation evaluations. On a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), a significant improvement in perception of comfort with managing the emergent pediatric airway was noted (2.7 to 4.6, p < .0001). Further, 94% of participants reported they strongly agreed (71%) or agreed (23%) that each station added to their perceived knowledge, skills, and attitudes of pediatric airway management. Discussion: After participating in our curriculum, participants self-reported improved comfort in managing the emergent pediatric airway. This curriculum provides educators with resources to navigate the paradigm of obtaining and maintaining competency of a rare but critical skillset.

A Teenager With Acute Anterograde Amnesia.

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department.

INTRODUCTION: Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation. METHODS: Pediatric emergency medicine fellows at a children's hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys. RESULTS: Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline). CONCLUSIONS: A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.

Providers' Perceptions of Caring for Pediatric Patients in Community Hospital Emergency Departments: A Mixed-methods Analysis.

BACKGROUND: Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children's hospitals. There is a paucity of information of perceptions on pediatric care from CED providers. This information is needed to guide the development of strategies to improve CED pediatric readiness. OBJECTIVE: The objective was to explore interprofessional CED providers' perceptions of caring for pediatric patients. METHODS: A preparticipation survey collected data on demographics, experience, and comfort in caring for children. Emergency pediatric simulations were then utilized to prime interprofessional teams for debriefings. These discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes through an inductive method derived from grounded theory. The other authors participated in confirmability and dependability checks. RESULTS: A total of 171 community hospital providers from six CEDs completed surveys (49% nurses, 22% physicians, 23% technicians). The majority were PALS trained (70%) and experienced fewer than five pediatric resuscitations in their careers (61%). Most self-reported comfort in caring for acutely ill and injured children. From the debriefings, three major challenge themes emerged: 1) knowledge and skill limitations attributed to infrequency of training and actual clinical events, 2) the emotional toll of caring for a sick child, and 3) acknowledgment of pediatric specific quality and safety deficits. Subthemes focused on causes and potential mitigating factors contributing to these challenges. A solution theme highlighted novel partnering opportunities with local children's hospitals. CONCLUSION: Interprofessional CED providers perceive that caring for pediatric patients is challenging due to case infrequency, the emotional toll of caring for sick children, and pediatric quality and safety deficits in their systems. These areas of focus can be used to generate specific strategies for improving CED pediatric readiness.

Identifying discordance between senior physicians and trainees on the root cause of ED revisits.

OBJECTIVE: Analysis of 72-hour ED revisits is a common emergency medicine quality assurance (QA) practice. Our aim was to compare the perceived root cause for 72-hour ED revisits between senior physicians (attendings) and trainees. We proposed that discordance in perception of why the revisit occurred would guide improvements in 72-hour revisits QA and elucidate innovative educational opportunities. METHODS: Questionnaire-based observational study conducted in an urban academic paediatric ED. Treating attendings and trainees independently completed questionnaires on revisit cases. The primary outcome was the revisit's perceived root cause, dichotomised into 'potential medical deficiency' or 'not potential medical deficiency'. Discordance between provider pairs was measured, stratified by revisit disposition. RESULTS: During the study period, 31 630 patients were treated in the ED, 559 returned within 72 hours and 218 met inclusion criteria for paired analysis. The proportion of cases assigned 'potential medical deficiency' by the attending and trainee was 13% and 9%, respectively. Discordance in the dichotomised root cause between attendings and trainees was 17% (38/218, 95% CI 12% to 22%). Revisit cases requiring admission revealed attending-trainee discordance of 25% (23/92, 95% CI 16% to 34%). CONCLUSIONS: Attendings and trainees frequently disagree on whether a potential medical deficiency was the root cause for an ED revisit, with more disagreement noted for cases requiring admission. These findings support the premise that there may be opportunities to improve 72-hour revisits QA systems through trainee integration. Finally, reuniting attending-trainee pairs around revisit cases may be a novel educational opportunity.