Improving the Procedure of Delivering Serious News: Impact of a Six-Month Curriculum for Second Year Pediatric Residents.

Objective: We implemented and studied a novel curriculum that combined role play, didactic education, and the use of a procedure card for asynchronous learning to improve second-year pediatric residents' skills in delivering serious news. Design: Phase 1 established baseline performance with a self-efficacy survey and observed simulation delivering serious news. Phase 2 included directed education of participants with a validated communication skills training framework. During Phase 3, participants were instructed to review the communication procedure card as a just-in-time reference prior to delivering serious news to patients and their families over 6 months. Following this period, participants completed a second self-efficacy survey and engaged in another observed simulation session delivering serious news. Pre and post intervention performance and self-efficacy were compared. Results: A total of 21 out of 26 (81%) participants completed all phases of this study. Participants had a statistically significant increase (p < .001) in self-efficacy scores post-intervention compared to pre-intervention for each of the skills to effectively deliver serious news: assess understanding, communicate news clearly, allow for silence, respond to emotion, and equip for next steps. Additionally, investigator assessments of participants showed an overall statistically significant improvement (p < .001) in all five communication skills post intervention compared to pre intervention. Conclusions: This curriculum resulted in significantly improved self-efficacy and observed ratings of communication skills in second-year pediatric residents over a 6-month period.

Teaching Communication as a Procedure by Utilizing a Mixed-Methods Curriculum: A Pilot Study.

Objective In this study, we aimed to develop and pilot a mixed-methods curriculum among pediatric subspecialty fellows that combined didactics, role-play, and bedside coaching with a procedure card. We hypothesized that this curriculum would improve fellows' ability to navigate difficult conversations and would be feasible to implement across training programs. Methods This study was conducted from 2019 to 2020. Phase 1 focused on establishing baseline performance. Phase 2 involved the education of participants and faculty. During phase 3, participants communicated difficult news to patients and families using the procedure card as a prompt with the aid of faculty coaching. Six months later, participants' performance was re-evaluated and compared with baseline performance. Results A total of 10 out of 17 (60%) participants completed the pilot study. Likert self-efficacy results revealed an improvement in the skill of delivering difficult news (3.0 pre-intervention, 4.1 post-intervention, p=0.0001), conducting a family conference (2.5 pre-intervention, 3.6 post-intervention, p=0.0001), and responding to emotions (3.4 pre-intervention, 4.2 post-intervention, p=0.0003). Investigator assessments showed improvement in fellows' ability to communicate information clearly (2.5 pre-intervention, 3.9 post-intervention, p=0.0001) and demonstrate empathy (2.7 pre-intervention, 3.3 post-intervention, p=0.005). Conclusions In this pilot study, coaching at the bedside with a procedure-card prompt was effective at improving specific self-perceived and observed communication skills. Future research is needed to evaluate modifications to this curriculum to enhance its feasibility.

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.

Advocating for Your Patients and Families: Simulation as an Educational Tool for Home Caregivers of Children with Chronic Conditions.

Simulation-based education for home caregivers of children with chronic conditions provides hands-on training set in a safe, confidential, supportive learning environment that is founded on the principles of patient-and family-centered care. This type of education and approach has been favored over traditional educational methods and may also improve caregivers' comfort, confidence, knowledge, skills, and ability to manage their child's routine and emergent care at home. Pediatricians play a vital role in this type of education as an advocate for their patients and families and as key stakeholders and collaborators in the process. Open collaboration and information sharing among home caregivers, simulation experts, pediatricians, and the rest of the medical team can lead to the development and implementation of successful simulation curricula. This in turn has the potential to lead to improved patient safety, quality of care, and patient outcomes. [Pediatr Ann. 2021;50(1):e39-e43.].

A Provider-Focused Intervention to Promote Optimal Care of Pediatric Patients With Suspected Elbow Fracture.

OBJECTIVE: Emergency department (ED) and urgent care (UC) physicians' accurate assessment of the neurovascular and musculoskeletal (NV/MSK) examination in pediatric patients with suspected elbow fracture is crucial to the early recognition of neurovascular compromise. Our objective was to determine the impact of computer-based simulation (CBS) and computerized clinical decision support systems (CCDSS) on ED and UC physicians' assessment of the NV/MSK examination of pediatric patients with elbow fracture as noted in their documentation. METHODS: All ED UC physician participants received CBS training about management of pediatric patients with suspected elbow fracture. Participants were then randomized to receive CCDSS (intervention arm) when an eligible patient was seen or no further intervention (comparison arm.) Participants received feedback on the proportion of patients with discharge diagnosis of elbow fracturewith proper examination elements documented. RESULTS: Twenty-eight ED and UC physicians were enrolled - 14 in each arm. Over the span of 16 weeks, 50 patients with a discharge diagnosis of elbow fracture were seen - 25 in each arm. Twenty-two of 25 (88%) patients seen by intervention arm participants had a complete NV/MSK examination documented. Six of 25 (24%) patients seen by comparison arm participants had a complete NV/MSK examination documented. Elements most commonly missed in the comparison arm included documentation of ulnar pulse as well as radial, median, and ulnar nerve motor functions. CONCLUSIONS: Compared with single CBS training alone, repeated exposure to CCDSS after CBS training resulted in improved documentation of the NV/MSK status of pediatric patients with elbow fracture.

The Impact of a Displayed Checklist on Simulated Pediatric Trauma Resuscitations.

BACKGROUND: Advanced Trauma Life Support resuscitation follows a strict protocolized approach to the initial trauma evaluation. Despite this structure, elements of the primary and secondary assessments can still be omitted. The aim of this study is to determine if a cognitive aid checklist reduces omissions and speeds the time to assessment completion. We additionally investigated if a displayed checklist improved performance further. METHODS: A series of 131 simulated trauma resuscitations were performed. Teams were randomized to 1 of 3 arms (no checklist, handheld checklist, or displayed). The scenarios were recorded and analyzed to determine time to completion and absolute completion of tasks of the primary and secondary survey. The workload of individual team members was assessed via NASA-TLX. RESULTS: There was no difference in time to completion of surveys among the 3 arms. In the primary survey, there was a nonsignificant increase in the number of completed tasks with the use of the displayed checklist. In the secondary survey, there was a significant improvement in task completion with the displayed checklists with improved evaluation of the pelvis (P = 0.011), lower extremities (P = 0.048), and covering the patient (P = 0.046). There was a significant improvement in performance in those reported among nurse documenters with use of the displayed checklist. CONCLUSIONS: Despite a structured approach to trauma resuscitations, omissions still occur. The use of a displayed checklist improves performance and reduces omissions without delaying assessment. Better compliance with Advanced Trauma Life Support protocols may improve patient outcomes.

Telesimulation-based education during COVID-19.

Simulation is a valuable, immersive educational tool for both health professional trainees and experienced clinicians. By promoting a realistic, collaborative, safe, hands-on, learning environment, simulation allows interprofessional teams to come together and practise both routine and high stakes, low-frequency events. The COVID-19 pandemic and the need for social distancing have shifted traditional simulation-based medical education towards a virtual platform: telesimulation. Telesimulation is an evolving field and the speed at which clinical educators need to adapt to use this platform is unprecedented. Educators must quickly navigate and leverage the differences between traditional simulation and telesimulation to create robust remote educational experiences. Telesimulation has unique goals and objectives, technology needs, and participant roles that need to be understood and properly operationalized to maximize opportunities for learning. This article reviews the authors' recommendations for developing and delivering successful telesimulations.

Use of simulation to develop a COVID-19 resuscitation process in a pediatric emergency department.

The coronavirus disease 2019 (COVID-19) pandemic has created many challenges for health care providers. At the forefront is the need to balance optimal patient care with the safety of those providing that care. This is especially true during resuscitations where life-saving procedures cause widespread aerosolization of the virus. Efforts to mitigate this exposure to front-line providers are therefore paramount. We share how we used simulation to prepare our pediatric emergency department for COVID-19 resuscitations.

Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia.

Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers' antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers' CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non-guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician's selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.

Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department.

Closed-loop communication (CLC) promotes a shared understanding of information. The authors hypothesized that simulation-based CLC training would improve staff perceptions of CLC ability and decrease medical errors. Participants experienced 2 hands-on CLC simulations one month apart. A retrospective chart review of Emergency Severity Index (ESI) 1 patients was conducted 4 months pre and post CLC simulation-based training. Seventy simulations were held over 13 weeks. Staff perceptions of CLC ability improved and were sustained after one month. Nine ESI 1 patients were seen pre CLC, and 9 post; 8/9 pre-CLC ESI 1 patients had medical errors, with 19 total errors noted; 5/9 post-CLC ESI 1 patients had medical errors, with 5 total errors noted (rate ratio [99% CI] = 3.8 [1.4, 10.2]; P = .008). This simulation-based CLC training curriculum improved staff perceptions of their CLC ability and was associated with a significant decrease in the number of medical errors in ESI 1 patients.

Cost-effectiveness of a video game versus live simulation for disaster training.

Introduction: Disaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game '60 s to Survival' would be a cost-effective alternative to live simulation-based PDT training. Methods: We synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC). Results: The total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective. Conclusions: A video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study.

BACKGROUND: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. OBJECTIVE: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. METHODS: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. RESULTS: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. CONCLUSIONS: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.

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.

Provider-Focused Intervention to Promote Comprehensive Screening for Adolescent Idiopathic Scoliosis by Primary Care Pediatricians.

Screening can detect adolescent idiopathic scoliosis (AIS). The objective was to determine if computer-based simulation (CBS) and computerized clinical decision-support systems (CCDSS) would improve primary care providers' AIS screening exams as noted in their documentation. All participants received AIS screening CBS training. Participants were then randomized to receive either CCDSS when an eligible patient was seen (intervention arm) or no further intervention (comparison arm). Eligible patients' documentation was analyzed looking for a complete AIS screening exam. Over the span of 17 weeks, 1051 eligible patients were seen; 468 by providers in the intervention arm, 583 in the comparison arm. In all, 292/468 (62%) of eligible patients seen in the intervention arm and 0/583 (0%) in the comparison arm had a complete AIS screening exam documented. Compared with single CBS training alone, repeated exposure to CCDSS after CBS training resulted in improved documentation of the screening exam for AIS.

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.

Electronic health record as a research tool: Frequency of exposure to targeted clinical problems and health care providers' clinical proficiency.

OBJECTIVES: The Electronic Health Record (EHR) could provide insight into possible decay in health care providers' (HCP) clinical knowledge and cognitive performance. Analyses of the contributions of variables such as frequency of exposure to targeted clinical problems could inform the development and testing of appropriate individualized interventions to mitigate these threats to quality and safety of care. MATERIALS/METHODS: Nine targeted clinical problems (TCP) were selected for further study, and de-identified, aggregated study data were obtained for one calendar year. Task analysis interviews of subspecialty physicians defined optimal management of each TCP and guided specification of quality of care metrics that could be extracted from the EHR. The Δ-t statistic, days since the provider's prior encounter with a given TCP, quantified frequency of exposure. RESULTS: Frequency of patient encounters ranged from 1566 to 220,774 visits across conditions. Mean Δ-t ranged from 1.72days to 30.79days. Maximum Δ-t ranged from 285 to 497days. The distribution of Δ-t for the TCPs generally fit a Gamma distribution (P<0.001), indicating that Δ-t conforms to a Poisson process. A quality of care metric derived for each TCP declined progressively with increasing Δ-t for 8 of the 9 TCPs, affirming that knowledge decay was detectable from EHR data. DISCUSSION/CONCLUSIONS: This project demonstrates the utility of the EHR as a research tool in studies of health care delivery in association with frequency of exposure of HCPs to TCPs. Subsequent steps in our research include multivariate modeling of clinical knowledge decay and randomized trials of pertinent preventive interventions.

Simulation training for primary caregivers in the neonatal intensive care unit.

Simulation is a hands-on educational modality that creates a safe, confidential learning environment that is closely aligned with the principles of patient- and family-centered care. This makes it an ideal training tool for families and caregivers of medically complex infants as they prepare for their care at home. Multidisciplinary collaboration and participation is vital to the success of these simulations and encourages the development of needs assessments and learning objectives that are congruent with the family's goals, beliefs, and culture. Simulation scenarios and curricula may be tailored and delivered in ways that optimize learning and allow for outcomes to be measured. Debriefing with specific and supportive feedback may increase families' and caregivers' confidence in handling their child's medical issues. This may lead to improved patient safety and quality of care delivered in the home environment.

Pulmonary lymphangioma in a 14-month-old.

Intrapulmonary lymphangiomas are very rare. We report a case of a 14-month-old child found to have a pulmonary lymphangioma on routine chest radiograph in the emergency department and discuss the possible implications and appropriate management of this condition by the emergency physician.

Hemorrhagic shock resulting from post-coital vaginal bleeding in an adolescent with Ehlers-Danlos type IV.

Multiple cases of obstetric-related vaginal bleeding exist in the medical literature pertaining to affected people with Ehlers-Danlos syndrome. We present a novel case of a 16-year-old female with vascular Ehlers-Danlos syndrome (formerly Ehlers-Danlos type IV) who was brought to the emergency department with brisk vaginal bleeding after her first episode of sexual intercourse.