A comparison between sudden cardiac arrest on military bases and non-military settings.

INTRODUCTION: Out-of-hospital cardiac arrests contribute to significant morbidity and mortality in both non-military/civilian and military populations. Early CPR and AED use have been linked with improved outcomes. There is public health interest in identifying communities with high rates of both with the hopes of creating generalizable tactics for improving cardiac arrest survival. METHODS: We examined a national registry of EMS activations in the United States (NEMSIS). Inclusion criteria were witnessed cardiac arrests from January 2020 to September 2022 where EMS providers documented the location of the arrest, whether CPR was provided prior to their arrival (yes/no), and whether an AED was applied prior to their arrival (yes/no). Cardiac arrests were then classified as occurring on a military base or in a non-military setting. RESULTS: A total of 60 witnessed cardiac arrests on military bases and 202,605 witnessed cardiac arrests in non-military settings met inclusion criteria. Importantly, the prevalence of CPR and AED use prior to EMS arrival was significantly higher on military bases compared to non-military settings. CONCLUSIONS: Reasons for the trends we observed may be a greater availability of CPR-trained individuals and AEDs on military bases, as well as a widespread willingness to provide aid to victims of cardiac arrest. Further research should examine cardiac arrests on military bases.

Medication Use in the Diagnostic Pediatric Lumbar Puncture.

The lumbar puncture (LP) is a common procedure in the pediatric emergency department. A retrospective review was conducted of patients who had LPs from 2012 to 2016 at 2 children's hospitals to (1) characterize medication use during the pediatric LP and (2) test the hypothesis that varied medication use influences LP outcome. Outcomes were defined as unsuccessful if the LP was documented as unsuccessful, had a cerebrospinal fluid (CSF) red blood cell (RBC) count >400 cells/µL, or if a second LP was performed within 24 hours. In total, 8463 patients were reviewed and 2806 (33%) were included in the study. We noted significant variation in LP medication use. When adjusted for patient demographics, location, weight, position, and provider experience, our regression model revealed that the use of fentanyl, ketamine, nitrous oxide, and propofol were best associated with LP success. These data suggest the need for a standardized LP medication protocol as provider choice in medication significantly influences LP outcome.

Case-Based Virtual Escape Rooms: Using Feedback to Change Online Platforms.

Introduction Virtual escape rooms (VERs) have provided education in healthcare settings. VERs were developed to provide medical education related to pediatric toxicology. This study explores simulation technologies, specifically portals to create and host VERs, including Google Sites, a website-building platform, and Articulate 360, an e-learning platform. The design objective was to create an engaging educational tool using a VER on two pediatric toxicology scenarios. Methods Case-based VERs were developed on Google Sites and Articulate 360. The cases focused on organophosphate toxicity and acute iron toxicity. Google Sites technology was used to build the organophosphate toxicity case, which was implemented and piloted with emergency medicine (EM) trainees in India and workshop participants at the International Pediatric Simulation Symposia and Workshops (IPSSW) in 2022. The iron toxicity case was developed using Articulate 360 and piloted at IPSSW in 2023. Feedback was collected as a survey from participants. Questions focused on using VERs as an engaging educational model, benefits, areas for improvement, and future participation in VERs. Following the study, a focus group meeting was held with facilitators and developers and subsequently analyzed. Results Evaluations from participants and a focus group provided data demonstrating both platforms' utility. Participants completed surveys after each VER. Overall, 84.2% of respondents (n=60) from EM training programs in India, 90.9% of respondents (n=11) from IPSSW in 2022, and 100% of respondents (n=23) from IPSSW in 2023 agreed or strongly agreed that this was an engaging education model. Conclusion Different platforms may be used to develop engaging VERs for gamification in education. This study found that VERs based on pediatric toxicology scenarios created on Google Sites and Articulate 360 are engaging educational tools for distance learning. Simulation technologies have benefits and disadvantages for Google Sites and Articulate 360. Simulation developers and educators should consider time, funding, technological needs, and participant feedback when deciding which portal to choose when building a VER.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

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.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

ACEP SimBox: A Pediatric Simulation-Based Training Innovation.

Thirty million pediatric visits (<18 years old) occur across 5,000 US emergency departments (EDs) each year, with most of these cases presenting to community EDs. Simulation-based training is an effective method to improve and sustain EDs' readiness to triage and stabilize critically ill infants and children, but large simulation centers are mostly concentrated at academic hospitals. The use of pediatric simulation-based training has been limited in the community ED setting due to the high cost of equipment and limited access to content experts in pediatric critical care. We designed an innovative "off-the-shelf" simulation-based training resource, "American College of Emergency Physicians (ACEP) SimBox," that provides a free low-technology manikin along with teaching aids and train-the-trainer materials to community EDs to run a simulation drill in their own workspaces with local educators. The goal was to develop an "off-the-shelf," free, open-access, simulation-based resource to improve the readiness of community EDs to triage, resuscitate, and transfer critically ill infants as measured by presimulation and postsimulation surveys measuring opinions regarding the scenario, session experience, and most valuable aspect of the session. Between January 2018 and December 2019, 179 ACEP SimBoxes were shipped across the United States, reaching 36 of 50 states. Facilitators and participants who completed the postsimulation survey evaluated the session as a valuable use of their time. All facilitator respondents reported that the low-technology manikins, paired with their institution-specific equipment, were sufficient for learning, thus reducing costs. All participant respondents reported an increased commitment to pediatric readiness for their ED after completing the simulation session. This innovation resulted in the implementation of a unique simulation-based training intervention across many community EDs in the United States. The ACEP SimBox innovation demonstrates that an easy to use and unique simulation-based training tool can be developed, distributed, and implemented across many community EDs in the United States to help improve community ED pediatric readiness.

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.

Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations.

Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.

Management of pediatric hypothermia and peripheral cold injuries in the emergency department.

Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures. This issue reviews the stages of hypothermia and offers recommendations for emergent management of pediatric patients with hypothermia; guidance is also provided for the identification and management of frostnip and frostbite.

60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills.

OBJECTIVES: Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy. METHODS: This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks. RESULTS: In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001). CONCLUSION: 60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.

60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers.

INTRODUCTION: Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game "60 Seconds to Survival" (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S. METHODS: Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method. RESULTS: There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335). CONCLUSION: The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Implementation of Electronic Clinical Decision Support for Pediatric Appendicitis.

BACKGROUND AND OBJECTIVE: Computed tomography (CT) and ultrasound (US) are commonly used in patients with acute abdominal pain. We sought to standardize care and reduce CT use while maintaining patient safety through implementation of a multicomponent electronic clinical decision support tool for pediatric patients with possible appendicitis. METHODS: We conducted a quasi-experimental study of children 3 to 18 years old who presented with possible appendicitis to the pediatric emergency department (ED) between January 2011 and December 2013. Outcomes were use of CT and US. Balancing measures included missed appendicitis, ED revisits within 30 days, appendiceal perforation, and ED length of stay. RESULTS: Of 2803 patients with acute abdominal pain over the 3-year study period, 794 (28%) had appendicitis and 207 (26.1% of those with appendicitis) had a perforation. CT use during the 10-month preimplementation period was 38.8% and declined to 17.7% by the end of the study (54% relative decrease). For CT, segmented regression analysis revealed that there was a significant change in trend from the preimplementation period to implementation (monthly decrease -3.5%; 95% confidence interval: -5.9% to -0.9%; P = .007). US use was 45.7% preimplementation and 59.7% during implementation. However, there was no significant change in US or total imaging trends. There were also no statistically significant differences in rates of missed appendicitis, ED revisits within 30 days, appendiceal perforation, or ED length of stay between time periods. CONCLUSIONS: Our electronic clinical decision support tool was associated with a decrease in CT use while maintaining safety and high quality care for patients with possible appendicitis.