Dissemination, Utilization, and Satisfaction With Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) by North American Residency Programs.

OBJECTIVES: Our research team's primary objective was to investigate how a custom standard simulation curriculum for teaching emergency medicine residents about pediatrics was being used by programs across North America. We also wanted to know if program directors were satisfied with the curriculum and whether they had challenges with implementing it. Our long-term goal is to promote the Emergency Medicine Resident Simulation Curriculum for Pediatrics for use by all programs in the United States. METHODS: We distributed an electronic questionnaire to individuals who have downloaded the Emergency Medicine Resident Simulation Curriculum for Pediatrics in the form of an e-book from the Academic Life in Emergency Medicine Web site. The curriculum was marketed through national emergency medicine (EM) and pediatric emergency medicine (PEM) groups, PEM listserv, and through the International Network for Simulation-Based Pediatric Innovation, Research, and Education. We asked survey recipients how they used the curriculum, plans for future maintenance, satisfaction with curriculum use, and whether they had any challenges with implementation. Finally, we asked demographic questions. RESULTS: Most survey respondents were EM or PEM health care physicians in the United States or Canada. Respondents' primary goal of using the curriculum was resident education. Through assessment with the Net Promoter Score, satisfaction with the curriculum was net positive with users largely scoring as curriculum promoters. We found COVID-19 and overall time limitations to be implementation barriers, whereas learner interest in topics was the largest cited facilitator. Most responders plan to continue to implement either selected cases or the entire curriculum in the future. CONCLUSIONS: Of those who responded, our target audience of EM physicians used our curriculum the most. Further investigation on implementation needs, specifically for lower resource emergency programs, is needed.

Pediatric Toxidrome Simulation Curriculum: Jimson Weed Toxicity.

Introduction: Jimson weed is a poisonous plant containing tropane alkaloids that can cause anticholinergic toxicity. Recognition of anticholinergic toxidrome is important for prevention and management of potentially life-threatening complications of severe toxicity, including dysrhythmia and seizure. Methods: Designed for pediatric emergency medicine (PEM) fellows, this simulation featured a 15-year-old female presenting to the emergency department (ED) with agitation and hallucinations. The team was required to perform a primary survey of the critically ill patient, recognize anticholinergic toxidrome from jimson weed intoxication, and treat complications of severe anticholinergic toxicity. Learners practiced critical resuscitation skills such as management of generalized tonic-clonic seizure, endotracheal intubation, synchronized cardioversion, and external cooling measures. A debriefing guide and participant evaluation forms were utilized. This simulation was created as both an in-person and a virtual simulation experience to accommodate COVID-19 social distancing guidelines. Results: Seventeen PEM fellows completed this simulation across three institutions (two in person, one virtual). Using 5-point Likert scales (with 5 being the most relevant or effective), participants rated the simulation as relevant to their work (M = 4.8, SD = 0.5) as well as effective in teaching basic resuscitation skills (M = 4.7, SD = 0.5), management of generalized tonic-clonic seizure (M = 4.8, SD = 0.5), and treatment of ventricular tachycardia with appropriate interventions (M = 4.6, SD = 0.5). Discussion: This simulation scenario allows pediatric medicine trainees in the ED to practice recognition and management of anticholinergic toxicity and its severe complications secondary to jimson weed ingestion.

A review of coxiellosis (Q fever) and brucellosis in goats and humans: Implications for disease control in smallholder farming systems in Southeast Asia.

Coxiella burnetii and Brucella spp. are pathogenic bacteria that can cause large-scale outbreaks in livestock. Furthermore, these infectious agents are capable of causing zoonotic infections and therefore pose a risk to the close relationship between farm households and their livestock, especially goats. A review of seroprevalence studies of Coxiella burnetii and Brucella spp. in domestic goats demonstrated large differences in the total number of samples tested in different regions and countries. This review aims to provide information on coxiellosis (Q fever in humans) and brucellosis in goats concerning the characteristics of the causative agent, surveillance, and available prevention and control measures at a global level. Implications for Coxiella burnetii and Brucella spp. infections in domesticated goats in Southeast Asia are discussed.

Infected Thornwaldt Cyst: Case Report of an Unusual Cause of Pediatric Neck Pain.

BACKGROUND: The differential diagnosis for pediatric neck pain is broad and includes benign and life-threatening entities. The neck is a complex structure with many compartments. Rare disease processes exist that can mimic more serious conditions, such as meningitis. CASE REPORT: We present a case of a teenager with several days of severe pain underneath her left jaw, limiting the motion of her neck. After laboratory and imaging evaluation, the patient was found to have an infected Thornwaldt cyst and was subsequently admitted for IV antibiotic treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Including infected congenital cysts on the differential for pediatric neck pain can help ensure appropriate use of invasive procedures, such as lumbar puncture. Missed cases of infected congenital cysts could lead to patients returning to the emergency department with persistent or worsened symptoms.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room.

Background: Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum. Methods: EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues. Results: Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively. Conclusions: Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows.

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.

How Prepared Are They? Pediatric Boot Camps and Intern Performance.

OBJECTIVE: To determine whether participation in a pediatric boot camp during medical school was associated with higher intern performance. Secondary objectives were to determine whether participation in general boot camps, pediatric subinternships or pediatric electives was associated with higher performance. METHODS: Intern surveys and faculty performance assessments during early internship were collected from a convenience sample of pediatric residency programs. Interns completed a survey regarding participation in medical school boot camps, pediatric subinternships and pediatric electives. Faculty assessed intern performance on selected Milestone-based subcompetencies on a 5-point scale following each intern's initial inpatient rotation and results were compared between groups. RESULTS: Seventeen pediatric residency programs participated. Two hundred eighty-seven interns completed the survey (69%), and faculty completed assessments on 71% of these interns. Of interns with complete faculty assessments (n = 198), 25% participated in 5 or more days of pediatric boot camp, 30% in general boot camp, and 45% in no boot camp. There were no educationally significant associations between participation in 5 or more days of pediatric boot camp, general boot camp, subinternships, or electives and intern performance. Interns completing at least 10 days of pediatric boot camp (n = 25) had slightly higher ratings for incorporating feedback and engaging in help-seeking behavior during June and July only. CONCLUSIONS: Participation in pediatric boot camps, general boot camps, pediatric subinternships or electives was not associated with substantially higher intern performance as measured by selected Milestone subcompetencies. Pediatric educators should carefully consider boot camp curricula and anticipated outcomes associated with boot camp participation.

International Pediatric Emergency Medicine and Critical Care Fellow Education: Utilizing Virtual Resuscitation Simulation in Settings With Differing Resources.

Pediatric Emergency and Critical Care-Kenya (PECC-Kenya) is an international collaboration between the University of Nairobi and the University of Washington (UW) supporting a combined fellowship program in pediatric emergency medicine (PEM) and pediatric critical care medicine (PCCM) in Kenya. Typically, PEM/PCCM faculty from UW travel to Kenya to support in-person simulation, which was cancelled due to COVID-19 travel restrictions. This presented a need for alternative modalities to continue simulation-based education. This technical report describes the use of virtual simulation for pediatric emergency and critical care fellow education on the management of hypovolemic and septic shock, utilizing international guidelines and being based on resource availability.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS) Telesimulation Series: Hyperleukocytosis.

Introduction: Hyperleukocytosis, an infrequent presentation of new-onset leukemia, is a medical emergency requiring prompt recognition and treatment. It can include altered mental status, fever, critical electrolyte derangements, and coagulopathies. Due to the COVID-19 pandemic, this simulation was created as a telesimulation in order to adhere to mandatory physical distancing guidelines while addressing learning objectives. Methods: This simulation was designed for pediatric emergency medicine fellows and featured a pediatric patient presenting with fever, altered mental status, and respiratory distress. After an initial assessment and appropriate workup, the patient developed tumor lysis syndrome, coagulopathies, and new-onset neurologic changes requiring appropriate interventions. A debriefing guide and participant evaluation form were utilized. Results: This telesimulation was implemented at five different institutions, with evaluation surveys completed by 22 pediatric emergency medicine fellows. The scenario was rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and was generally well received, with participants rating the simulation as effective in teaching the recognition (M = 4.8) and management (M = 4.6) of hyperleukocytosis. Participants felt that virtual telesimulation was effective compared to other distance learning methods (M = 3.9). Discussion: This simulation-based curriculum allows learners to practice identifying and managing hyperleukocytosis. We found that it was well received in both in-person and virtual formats.

Nitrous Oxide Sedation Asynchronous Curriculum for Pediatric Emergency Medicine Providers.

This technical report describes a nitrous oxide sedation training curriculum for pediatric emergency medicine providers. This curriculum was used during the novel coronavirus disease 2019 (COVID-19) pandemic where in-person classroom training was significantly limited. We demonstrate a model for concept and equipment learning with video-guided self-practice in place of in-person training with a facilitator. A similar model can be utilized for other equipment or concept training.

Creation of a standardized pediatric emergency medicine simulation curriculum for emergency medicine residents.

BACKGROUND: The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills. METHODS: All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation. RESULTS: Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation. CONCLUSIONS: Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study.

OBJECTIVES: Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices. METHODS: This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated. RESULTS: Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations. CONCLUSIONS: Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

TeleSimBox: A perceived effective alternative for experiential learning for medical student education with social distancing requirements.

INTRODUCTION: During the COVID-19 pandemic the Association of American Medical Colleges recommended that medical students not be involved with in-person patient care or teaching, necessitating alternative learning opportunities. Subsequently we developed the telesimulation education platform: TeleSimBox. We hypothesized that this remote simulation platform would be feasible and acceptable for faculty use and a perceived effective method for medical student education. METHODS: Twenty-one telesimulations were conducted with students and educators at four U.S. medical schools. Sessions were run by cofacilitator dyads with four to 10 clerkship-level students per session. Facilitators were provided training materials. User-perceived effectiveness and acceptability were evaluated via descriptive analysis of survey responses to the Modified Simulation Effectiveness Tool (SET-M), Net Promoter Score (NPS), and Likert-scale questions. RESULTS: Approximately one-quarter of students and all facilitators completed surveys. Users perceived that the sessions were effective in teaching medical knowledge and teamwork, though less effective for family communication and skills. Users perceived that the telesimulations were comparable to other distance learning and to in-person simulation. The tool was overall positively promoted. CONCLUSION: Users overall positively scored our medical student telesimulation tool on the SET-M objectives and promoted the experience to colleagues on the NPS. The next steps are to further optimize the tool.

Tips for Conducting Telesimulation-Based Medical Education.

Telesimulation utilizes communications technology, such as video conferencing platforms, to provide simulation-based medical education when participants and facilitators are geographically separated. Learners interact with each other, embedded participants, and a simulated patient and/or vital sign display on the computer screen. Facilitators observe the learners in real-time and provide immediate feedback during a remote debrief. Telesimulation obviates the need to have instructors, learners, and high fidelity patient simulators (HPS) in the same place, allowing simulation-based educational sessions to occur in institutions located remotely from simulation centers or when other barriers limit in-person education and/or training. For example, due to the novel coronavirus (COVID-19) pandemic, many medical education programs temporarily discontinued in-person simulations to adhere to physical distancing guidelines. The authors have reflected upon their experiences executing telesimulation sessions since the start of the pandemic and provide these 12 tips as practical suggestions on how to successfully implement telesimulations with medical trainees. These tips are intended to guide implementation and facilitation by staff and faculty trained in simulation.

Pediatric Toxidrome Simulation Curriculum: Lidocaine-Induced Methemoglobinemia.

Introduction: Lidocaine is a common local anesthetic used during minor procedures performed on pediatric patients. A rare but toxic and life-threatening side effect of lidocaine is methemoglobinemia. It should be considered in children who are hypoxic after exposure to an oxidizing agent. Methods: We developed this simulation case for pediatric emergency medicine (PEM) fellows, but it can be adapted for interprofessional simulation. The case involved a 1-month-old male with hypoxia and resulting central cyanosis after exposure to lidocaine. The team performed an initial evaluation and intervention, collected a history, and developed a differential diagnosis for hypoxia and central cyanosis in an infant. Methemoglobinemia was confirmed by CO-oximetry. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation. Results: Fifty-six participants (including 18 PEM fellows) completed this simulation across four institutions. Participants rated the scenario on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), finding it to be relevant to their work (median = 5) and realistic (median = 5). After participation in the simulation, learners felt confident in their ability to recognize methemoglobinemia (median = 4) and implement a plan to stabilize an infant with hypoxia (median = 4). Discussion: This simulation represents a resource for learners in the pediatric emergency department. It teaches the recognition and management of an infant with lidocaine toxicity and resultant methemoglobinemia. It uses experiential learning to teach and reinforce a systematic approach to the evaluation and management of a critically ill infant with acquired methemoglobinemia.

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn.

Introduction: The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods: This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results: The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion: This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

TeamSTEPPS online simulation: expanding access to teamwork training for medical students.

Background: The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) programme is an evidence-based approach to teamwork training. In-person education is not always feasible for medical student education. The aim of this study was to evaluate the impact of online, interactive TeamSTEPPS simulation versus an in-person simulation on medical students' TeamSTEPPS knowledge and attitudes. Methods: Fourth-year medical students self-selected into an in-person or online training designed to teach and evaluate teamwork skills. In-person participants received didactic sessions, team-based medical simulations and facilitated debriefing sessions. The online group received an equivalent online didactic session and participated in an interactive software-based simulation with immediate, personalised performance-based feedback and scripted debriefing. Both trainings used three iterations of a case of septic shock, each with increasing medical complexity. Participants completed a demographic survey, a preintervention/postintervention TeamSTEPPS Benchmarks test and a retrospective preintervention/postintervention TeamSTEPPS teamwork attitudes questionnaire. Data were analysed using descriptive statistics and repeated measures analysis of variance. Results: Thirty-one students (18 in-person, 13 online) completed preintervention/postintervention surveys, tests and questionnaires. Gender, age and exposure to interprofessional education, teamwork training and games were similar between groups. There were no statistical differences in preintervention knowledge or teamwork attitude scores between in-person and online groups. Postintervention knowledge scores increased significantly from baseline (+2.0% p=0.047), and these gains did not differ significantly based on whether participants received in-person versus online training (+1.5% vs +2.9%; p=0.49). Teamwork attitudes scores also showed a statistically significant increase with training (+0.9, p<0.01) with no difference in the effect of training by group (+0.8 vs +1.0; p=0.64). Conclusions: Graduating medical students who received in-person and online teamwork training showed similar increases in TeamSTEPPS knowledge and attitudes. Online simulations may be used to teach and reinforce team communication skills when in-person, interprofessional simulations are not feasible.