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.

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.

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs.

OBJECTIVES: Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs. METHODS: Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items. RESULTS: A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs. CONCLUSIONS: The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception.

INTRODUCTION: Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. METHODS: Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children's hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. RESULTS: After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. CONCLUSION: Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

Procedural Training and Assessment for Pediatric Emergency Medicine Physicians Within the United States and Canada: A Survey Study.

OBJECTIVES: The aims of this study were to determine current practices in procedural training and skill assessment for attending physicians working in pediatric emergency departments within the United States and Canada and identify barriers to providing training and assessment. METHODS: This was a cross-sectional survey study. Members of the pediatric emergency medicine fellowship program directors and associate program directors Listserv were invited to participate in an anonymous survey about attending physician training and assessment practices for 9 specific procedures and barriers to training and assessment. RESULTS: Eighty-two (56.2%) of 146 recipients responded, with 79 surveys fully completed; 58.5% of responders report that their division offers procedural training, whereas 14.6% report assessment of procedural skills. The most common procedure for which participants report training and assessment is orotracheal intubation (53.1% and 7.5%, respectively), with training rates for other procedures ranging from 2.5% to 43.0%. Most sites that report training use simulation in some form for education. For assessment, simulation is used almost exclusively. Cost (50.6%), lack of faculty interest (36.7%), and lack of standardized guidelines (36.7%) are the most common barriers to training. Lack of standardized guidelines (51.9%), cost (43.0%), and lack of faculty interest (38.0%) are the most common barriers for assessment. CONCLUSIONS: Although pediatric emergency medicine physicians may be required to perform emergent procedures, opportunities to receive training and assessment in these procedures are limited. Simulation and other educational modalities are being used to provide skill training and assessment, but cost and lack of resources, standardized protocols, and faculty interest are barriers to the implementation of training and assessment programs.

Crataegus mexicana (Tejocote) Exposure Associated with Cardiotoxicity and a Falsely Elevated Digoxin Level.

INTRODUCTION: A species of hawthorn, Crataegus mexicana (tejocote), has been marketed as a weight-loss supplement that is readily available for purchase online. While several hawthorn species have shown clinical benefit in the treatment of heart failure owing to their positive inotropic effects, little is known about hawthorn, and tejocote in particular, when consumed in excess. We describe a case of tejocote exposure from a weight-loss supplement resulting in severe cardiotoxicity. CASE REPORT: A healthy 16-year-old girl presented to an emergency department after ingesting eight pieces of her mother's tejocote root weight-loss supplement. At arrival, she was drowsy, had active vomiting and diarrhea, and had a heart rate of 57 with normal respirations. Her initial blood chemistries were unremarkable, except for an elevated digoxin assay of 0.7 ng/mL (therapeutic range 0.5-2.0 ng/mL). All other drug screens were negative. She later developed severe bradycardia and multiple episodes of hypopnea that prompted a transfer to our institution, a tertiary pediatric hospital. Her ECG demonstrated a heart rate of 38 and Mobitz type 1 second-degree heart block. She was subsequently given two vials of Digoxin Immune Fab due to severe bradycardia in the setting of suspected digoxin-like cardiotoxicity after discussion with the regional poison control center. No clinical improvement was observed. Approximately 29 hours after ingestion, subsequent ECGs demonstrated a return to normal sinus rhythm, and her symptoms resolved. DISCUSSION: Tejocote root toxicity may cause dysrhythmias and respiratory depression. Similar to other species of hawthorn, tejocote root may cross-react with some commercial digoxin assays, resulting in a falsely elevated level.

Transient Erythroblastopenia of Childhood: A Review for the Pediatric Emergency Medicine Physician.

Transient erythroblastopenia of childhood is a form of pure red cell aplasia that is self-limited and occurs in children 4 years old and younger. It is characterized by an absence or a significantly reduced quantity of erythroblasts in the bone marrow without underlying congenital red blood cell abnormalities. Transient erythroblastopenia of childhood should be considered in previously healthy children who present with normocytic anemia and lack of reticulocytosis without evidence of blood loss, hemolysis, or other causes of bone marrow suppression. Evaluation should be targeted at ruling out other causes of anemia. Management is mainly supportive, although some children may require blood transfusions for symptomatic anemia. Most patients demonstrate a return of hematopoiesis within two weeks of diagnosis and normalization of blood counts within two months.

Retrospective Cohort Study on the Optimal Timing of Orogastric Tube/Nasogastric Tube Insertion in Infants With Pyloric Stenosis.

BACKGROUND: Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. Currently, there are no evidence-based guidelines regarding OGT/NGT placement in these patients. This study examines whether OGT/NGT placement before arrival in the operating room was associated with a longer time to readiness for surgery as defined by normalization of electrolytes. Secondary outcomes included time from surgery to discharge and ability to tolerate feeds by 6 hours postoperatively in patients with and without early OGT/NGT placement. METHODS: In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. Multivariable linear regression and Cox proportional hazard models were constructed to evaluate the association between placement of an OGT/NGT at the time of admission with increased time to readiness for surgery (defined as the time from admission to the first set of normalized laboratory values) and increased time from surgery to discharge. Multivariable logistic regression was used to evaluate the association between early OGT/NGT placement and the ability to tolerate oral intake at 6 hours postsurgery. Analyses were adjusted for site differences. RESULTS: Among patients admitted with electrolyte abnormalities, those with an OGT/NGT placed on presentation required more time until their serum electrolytes were at acceptable levels for surgery by regression analysis (19.2 hours difference; 95% confidence interval, 10.05-28.41; P < .001), after adjusting for site. Overall, patients who had OGTs/NGTs placed before presentation in the operating room had a longer length of stay from surgery to discharge than those without (38.8 hours difference; 95% confidence interval, 25.35-52.31; P < .001), after adjusting for site. OGT/NGT placement before surgery was not associated with failure to tolerate oral intake within 6 hours of surgery after adjusting for site, corrected gestational age, and baseline serum electrolytes. CONCLUSIONS: OGT/NGT placement on admission for pyloric stenosis is associated with a longer time to electrolyte correction in infants with abnormal laboratory values on presentation and, subsequently, a longer time until they are ready for surgery. It is also associated with longer postoperative hospital stay but not an increased risk of feeding intolerance within 6 hours of surgical repair.

Are Graduating Pediatric Residents Prepared to Perform Infant Lumbar Punctures?: A Multi-Institutional Descriptive Study.

OBJECTIVES: Few published studies describe graduating pediatric residents' procedural skills or success rates. This information would help guide supervisors' decisions about graduating residents' preparedness, training, and supervision needs. This study aimed to measure success rates for graduating pediatric residents performing infant lumbar puncture (LP) during the final months of their training and to describe their experiences performing and supervising infant LPs during the course of their training. METHODS: This survey-based study was conducted at 10 academic medical institutions in 2013. The survey consisted of 4 domains: (1) demographics, (2) exposure to infant LP training as an intern, (3) number of LPs performed and supervised during residency, and (4) specific information on the most recent clinical infant LP. RESULTS: One hundred ninety-eight (82%) of 242 eligible graduating residents responded to the survey. A 54% success rate was noted for graduating residents when they were the first provider performing the infant LPs. Success rates were 24% if they were not the first provider to attempt the LP. Overall, graduating residents were supervised on 29% of their LPs, used anesthesia for 29%, and used the early stylet removal technique for 63%. The graduating residents performed a median of 12 infant LPs and supervised others on a median of 5 infant LPs throughout their residency. The vast majority reported feeling confident and prepared to perform this procedure. CONCLUSIONS: At the end of residency, graduating pediatric residents were rarely supervised and had low infant LP success rates despite confidence in their skills. However, graduating residents frequently supervised others performing this procedure.

An Objective Structured Clinical Examination to Improve Formative Assessment for Senior Pediatrics Residents.

BACKGROUND: Residency programs are developing new methods to assess resident competence and to improve the quality of formative assessment and feedback to trainees. Simulation is a valuable tool for giving formative feedback to residents. OBJECTIVE: To develop an objective structured clinical examination (OSCE) to improve formative assessment of senior pediatrics residents. METHODS: We developed a multistation examination using various simulation formats to assess the skills of senior pediatrics residents in communication and acute resuscitation. We measured several logistical factors (staffing and program costs) to determine the feasibility of such a program. RESULTS: Thirty-one residents participated in the assessment program over a 3-month period. Residents received formative feedback comparing their performance to both a standard task checklist and to peers' performance. The program required 16 faculty members per session, and had a cost of $624 per resident. CONCLUSIONS: A concentrated assessment program using simulation can be a valuable tool to assess residents' skills in communication and acute resuscitation and provide directed formative feedback. However, such a program requires considerable financial and staffing resources.

Tumor lysis syndrome: risk factors, diagnosis, and management.

Tumor lysis syndrome (TLS) is a potentially fatal complication of induction therapy for several types of malignancies. Electrolyte derangements and even downstream complications may also occur prior to the initial presentation to a medical provider, before an oncologic diagnosis has been established. It is therefore imperative that emergency physicians be familiar with the risk factors for TLS in children as well as the criteria for diagnosis and the strategies for prevention and management. Careful evaluation of serum electrolytes, uric acid, and renal function must occur. Patients at risk for TLS and those who already exhibit laboratory or clinical evidence of TLS require close monitoring, aggressive hydration, and appropriate medical treatment.

Portal venous gas emboli after accidental ingestion of concentrated hydrogen peroxide.

BACKGROUND: Hydrogen peroxide is a common household product. It is clear and odorless making it easy to confuse with water, especially when improperly stored. Concentrated formulations are also available for consumer purchase. OBJECTIVE: We report a case of hydrogen peroxide ingestion in a child and discuss the potential consequences and treatment of such an exposure. CASE REPORT: A 12-year-old boy accidentally ingested a sip of concentrated hydrogen peroxide. He rapidly developed hematemesis and presented to the Emergency Department. His initial work-up was unremarkable, and his symptoms resolved quickly. However, diffuse gas emboli were found within the portal system on abdominal computed tomography. The child was treated with hyperbaric oxygen therapy and later found to have gastric irritation as well as an ulcer on endoscopy. He recovered fully from the incident. CONCLUSIONS: We present this case to increase awareness of the dangers of hydrogen peroxide ingestion in children. Fortunately, the child in this case recovered fully, but emergency physicians should be aware of the potential consequences and therapeutic options.