Can Telemedicine Improve Adherence to Resuscitation Guidelines for Critically Ill Children at Community Hospitals? A Randomized Controlled Trial Using High-Fidelity Simulation.

OBJECTIVES: Children transferred from community hospitals lacking specialized pediatric care are more seriously ill than those presenting to pediatric centers. Pediatric consultation and adherence to management guidelines improve outcomes. The aims of the study were (1) to assess whether telemedicine consultation in critical situations is feasible and (2) to compare the impact of pediatric critical care medicine (PCCM) consultation via telemedicine versus telephone on community hospital adherence to resuscitation guidelines through a randomized controlled telemedicine trial. METHODS: In situ, high-fidelity simulation scenarios of critically ill children presenting to a community hospital and progressing to cardiopulmonary arrest were performed. Scenarios were randomized to PCCM consultation via telephone (control) or telemedicine (intervention). Primary outcome measure was proportion of teams who successfully defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia. RESULTS: The following 30 scenarios were completed: 15 control and 15 intervention. Only 11 (37%) of 30 teams, defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia; control: 6 (40%) of 15 versus intervention: 5 (33%) of 15, P = 0.7. Request for or use of backboard during cardiopulmonary resuscitation occurred in 24 (80%) of 30 scenarios; control: 9 (60%) of 15 versus intervention: 15 (100%) of 15, P = 0.006. Request for or use of stepstool during cardiopulmonary resuscitation occurred in 6 (20%) of 30 scenarios; control: 1 (7%) of 15 versus intervention: 5 (33%) of 15, P = 0.07. CONCLUSIONS: This study demonstrates the feasibility of using telemedicine to support acute management of children who present to community hospitals. Neither study arm adhered to current resuscitation guidelines and telemedicine consultation with PCCM experts was not associated with improvement. However, further research on optimizing telemedicine impact on the quality of pediatric care at community hospitals is warranted.

"ABC-SBAR" training improves simulated critical patient hand-off by pediatric interns.

OBJECTIVES: This study was done to assess whether a modified "ABC-SBAR" mnemonic (airway, breathing, circulation followed by situation, background, assessment, and recommendation) improves hand-offs by pediatric interns in a simulated critical patient scenario. METHODS: Each of 26 interns reviewed a scenario involving a decompensating pediatric patient and gave a simulated hand-off to a responder. They received a didactic session on ABC-SBAR, then performed a second hand-off using another scenario. Two blinded reviewers assessed 52 video-recorded hand-offs for inclusion, order, and elapsed time to essential hand-off information using a scoring tool. RESULTS: Mean score of hand-offs increased after ABC-SBAR training (preintervention: 3.1/10 vs postintervention: 7.8/10, P < 0.001). In hand-offs after ABC-SBAR training, the reason for the emergency call was more often prioritized before background information (preintervention: 4% vs postintervention: 81%, P < 0.001) and stated earlier (elapsed time preintervention: 19 seconds vs postintervention: 7 seconds, P < 0.001). Hand-offs including an airway or breathing assessment increased after training (preintervention: 35% vs postintervention: 85%, P = 0.001), and this information was also stated earlier (preintervention: 25 seconds vs postintervention: 5 seconds, P < 0.001). Total hand-off duration was increased (preintervention: 29 seconds vs postintervention: 36 seconds, P = 0.004). CONCLUSIONS: Unstructured hand-off by interns in a simulated patient emergency emphasizes background information, leaving essential information (such as reason for the call and ABCs) delayed or omitted. ABC-SBAR was associated with improved inclusion and timeliness of essential information in simulated critical patient hand-offs by pediatric interns; however, hand-off duration was increased. Further studies are needed to elucidate optimal hand-off in an emergency situation.

Food and Drug Administration approval for medications used in the pediatric intensive care unit: a continuing conundrum.

OBJECTIVES: Many drugs used in the pediatric intensive care unit are administered "off label," i.e., they have been neither thoroughly tested for efficacy and safety nor approved for use in children. The U.S. Congress has enacted legislation to promote standards and requirements for Food and Drug Administration labeling for drugs used in pediatrics. Nevertheless, we hypothesized that most medications used in our pediatric intensive care unit were not Food and Drug Administration approved for use in pediatric patients. DESIGN: A list of medications dispensed in the pediatric intensive care unit from January through February 2008 was obtained from our pharmacy database. We then determined whether each medication had been granted Food and Drug Administration approval for use in children. Medications were divided into the following categories: not approved for use in any pediatric age group, approved for use in limited age groups only, and approved for use in all pediatric age groups. SETTING: A pediatric intensive care unit at a tertiary care hospital with 26 beds and 1,500 admissions per year. MEASUREMENTS AND MAIN RESULTS: In the 2-month period, 248 different medications were dispensed with a total of 49,707 medication orders. Sixty (24.2%) of the medications dispensed were not Food and Drug Administration approved for use in any pediatric age group, 106 (42.7%) were approved for use in limited age groups, and 82 (33%) were approved for use in all pediatric age groups. Eleven of the 25 most frequently dispensed medications were approved for use in limited age groups, but none of them was used for the indication or age group for which they were approved. CONCLUSIONS: Despite the efforts of Congress, 67% of medications prescribed and administered in the pediatric intensive care unit did not have Food and Drug Administration approval or had only limited approval, underscoring the need for the medical community to demand oversight and research to improve drug labeling for our patient population.

Pediatric residents do not feel prepared for the most unsettling situations they face in the pediatric intensive care unit.

BACKGROUND: Critical care rotations involve emotionally unsettling situations with greater frequency and intensity than those that are encountered in other portions of residency training. New approaches are needed to optimize the preparation and professionalism of postgraduate medical trainees when managing crisis management scenarios. METHODS: An anonymous survey was conducted that focused on preparedness for dealing with emotionally unsettling situations, training preferences for these encounters, and the utility of resource personnel. A total of 58% of four classes of pediatric residents responded over a 2-year period. RESULTS: Pediatric residents in our program identified sudden patient death and conflicts about goals of care within the team as the most unsettling situations. These were also the scenarios with which they had the least experience and for which they felt least prepared. Team discussion was designated as the most helpful educational tool, in addition to a combination of didactic educational programs and end-of-rotation sessions. CONCLUSIONS: The focus and design of clinical education programming on preparation for crisis management during the care of critically ill patients benefit from the incorporation of trainee perceptions of preparedness and the efficacy of educational formats. Trainee feedback in these areas can be harnessed as a continuous quality improvement tool and as a metric of success in meeting professional training goals.