The Effect of a Collaborative Pediatric Emergency Readiness Improvement Intervention on Patients' Hospital Outcomes.

OBJECTIVE: We hypothesized that collaborative intervention to improve weighted pediatric readiness score (WPRS) will be associated with decreased pediatric intensive care (PICU) mortality, PICU and hospital length of stay. METHODS: This study analyzes the transfer of acutely ill and injured patients from general emergency departments (GEDs) to our institution. The intervention involved customized assessment reports focusing on team performance and systems improvement for pediatric readiness, sharing best practices and clinical resources, designation of a nurse PECC at each GED and ongoing interactions at 2 and 4 months. Data was collected from charts before and after the intervention, focusing on patients transferred to our pediatric emergency department (ED) or directly admitted to our PICU from the GEDs. Clinical outcomes such as PICU length of stay (LOS), hospital LOS, and PICU mortality were assessed. Descriptive statistics were used for demographics, and various statistical tests were employed to analyze the data. Bivariate analyses and multivariable models were utilized to examine patient outcomes and the association between the intervention and outcomes. RESULTS: There were 278 patients in the pre-intervention period and 314 patients in the post-intervention period. Multivariable analyses revealed a significant association between the change in WPRS and decreased PICU LOS (ß=-0.05 [95% CI: -0.09, -0.01), p=0.023), and hospital LOS (ß=-0.12 [95% CI: -0.21, -0.04], p=0.004), but showed no association between the intervention and other patient outcomes. CONCLUSIONS: In this cohort, improving pediatric readiness scores in GEDs was associated with significant improvements in PICU and hospital length of stay. Future initiatives should focus on disseminating pediatric readiness efforts to improve outcomes of critically ill children nationally. WHATS NEW: Improving pediatric readiness scores in general emergency departments is associated with improved downstream clinical outcomes demonstrated by reduced PICU and hospital length of stay.

The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments.

OBJECTIVES: Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients. METHODS: We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record. RESULTS: Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09). CONCLUSIONS: Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care.

Exploring cultural sensitivity during distance simulations in pediatric emergency medicine.

Background: Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities. Methods: This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups. Results: Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of "how to practice PEM." The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement. Conclusion: The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.

Evaluation of Pediatric Readiness Using Simulation in General Emergency Departments in a Medically Underserved Region.

BACKGROUND: Regionalization of pediatric care in the United States was developed to improve care by directing patients to hospitals with optimal pediatric resources and experience, leading to less pediatric-trained providers in medically underserved areas. Children with emergencies, however, continue to present to local general emergency departments (GEDs), where pediatric emergencies are low-frequency, high-risk events. OBJECTIVE: The goals of this project were to: increase exposure of GEDs in the southeast United States to pediatric emergencies through simulation, assess pediatric emergency clinical care processes with simulation, describe factors associated with readiness including volume of pediatric patients and ED location (urban/rural), and compare these findings to the 2013 National Pediatric Readiness Project. METHODS: This prospective in situ simulation study evaluated GED readiness using the Emergency Medical Services for Children Pediatric Readiness Score (PRS) and team performance in caring for 4 simulated pediatric emergencies. Comparisons between GED and pediatric ED (PED) performance and PRS, GED performance, and PRS based on pediatric patient volume and hospital location were evaluated. A Composite Quality Score (CQS) was calculated for each ED. RESULTS: Seventy-five teams from 40 EDs participated (39 GED; 1 PED). The PED had a significantly higher volume of pediatric patients (73,000 vs 4492; P = 0.003). The PRS for GEDs was significantly lower (57% [SD, 17] vs 98%; P = 0.022). The CQSs for all GEDs were significantly lower than the PED (55% vs 87%; P < 0.004). Among GEDs, there was no statistically significant difference in PRS or CQS based on pediatric patient volume, but urban GEDs had significantly higher CQSs versus rural GEDs (59.8% vs 50.6%, P = 0.001). CONCLUSIONS: This study shows a significant disparity in the performance and readiness of GEDs versus a PED in a medically underserved area. More education and better access to resources is needed in these areas to adequately care for critically ill pediatric patients.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation.

BACKGROUND: The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit. METHODS: This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework. RESULTS: Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized. CONCLUSIONS: Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation.

Background: Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings. Methods: We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking. Results: Small groups (n = 121) and survey ranking (n = 54) were used with distance, remote, and telesimulation as leading terms. Each was favored by a third of the participants without consensus. Conclusion: This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of distance, remote and telesimulation is preferred.

Comparison of a dichotomous versus trichotomous checklist for neonatal intubation.

BACKGROUND: To compare validity evidence for dichotomous and trichotomous versions of a neonatal intubation (NI) procedural skills checklist. METHODS: NI skills checklists were developed utilizing an existing framework. Experts were trained on scoring using dichotomous and trichotomous checklists, and rated recordings of 23 providers performing simulated NI. Videolaryngoscope recordings of glottic exposure were evaluated using Cormack-Lehane (CL) and Percent of Glottic Opening scales. Internal consistency and reliability of both checklists were analyzed, and correlations between checklist scores, airway visualization, entrustable professional activities (EPA), and global skills assessment (GSA) were calculated. RESULTS: During rater training, raters gave significantly higher scores on better provider performance in standardized videos (both p < 0.001). When utilized to evaluate study participants' simulated NI attempts, both dichotomous and trichotomous checklist scores demonstrated very good internal consistency (Cronbach's alpha 0.868 and 0.840, respectively). Inter-rater reliability was higher for dichotomous than trichotomous checklists [Fleiss kappa of 0.642 and 0.576, respectively (p < 0.001)]. Sum checklist scores were significantly different among providers in different disciplines (p < 0.001, dichotomous and trichotomous). Sum dichotomous checklist scores correlated more strongly than trichotomous scores with GSA and CL grades. Sum dichotomous and trichotomous checklist scores correlated similarly well with EPA. CONCLUSIONS: Neither dichotomous or trichotomous checklist was superior in discriminating provider NI skill when compared to GSA, EPA, or airway visualization assessment. Sum scores from dichotomous checklists may provide sufficient information to assess procedural competence, but trichotomous checklists may permit more granular feedback to learners and educators. The checklist selected may vary with assessment needs.

Improving Emergency Preparedness in Pediatric Primary Care Offices: A Simulation-Based Interventional Study.

OBJECTIVES: Pediatric emergencies pose a challenge to primary care practices due to irregular frequency and complexity. Simulation-based assessment can improve skills and comfort in emergencies. Our aim was improving pediatric office emergency preparedness, as measured by adherence to the existing American Academy of Pediatrics policy statement, and quality of emergency care in a simulated setting, as measured by performance checklists. METHODS: This was a single center study nested in a multicenter, prospective study measuring emergency preparedness and quality of care in 16 pediatric primary care practices and consisted of 3 phases: baseline assessment, intervention, and follow-up assessment. Baseline emergency preparedness was measured by checklist based on AAP guidelines, and quality of care was assessed using in-situ simulation. A report-out was provided along with resources addressing potential areas for improvement after baseline assessment. A repeat preparedness and simulation assessment was performed after a 6 to 10 month intervention period to measure improvement from baseline. RESULTS: Sixteen offices were recruited with 13 completing baseline and follow-up preparedness assessment. Eight of these sites also completed baseline and follow-up simulation assessment. Median baseline preparedness score was 70% and follow-up was 75.9%. Median baseline simulation performance scores were 37.4% and 35.5% for respiratory distress and seizure scenarios, respectively. Follow-up simulation assessment scores were 73% and 76.9% respectively (P = .001). CONCLUSIONS: Our collaborative was able to successfully improve the quality of care in a simulated setting in a group of pediatric primary care offices over 6 to 10 months. Future work will focus on expansion and improving emergency preparedness.

Improving Pediatric Readiness and Clinical Care in General Emergency Departments: A Multicenter Retrospective Cohort Study.

OBJECTIVE: To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs. STUDY DESIGN: This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: postsimulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network's Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders. RESULTS: A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention. CONCLUSION: A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.

Efficacy of Computer-Based Simulation as a Modality for Learning Pediatric Disaster Triage for Pediatric Emergency Nurses.

SUMMARY STATEMENT: Pediatric disaster triage (PDT) is challenging for healthcare personnel. Mistriage can lead to poor resource utilization. In contrast to live simulation, screen-based simulation is more reproducible and less costly. We hypothesized that the screen-based simulation "60 Seconds to Survival" (60S) to learning PDT will be associated with improved triage accuracy for pediatric emergency nursing personnel.During this prospective observational study, 138 nurse participants at 2 tertiary care emergency departments were required to play 60S at least 5 times over 13 weeks. Efficacy was assessed by measuring the learners' triage accuracy, mistriage, and simulated patient outcomes using JumpStart.Triage accuracy improved from a median of 61.1 [interquartile range (IQR) = 48.5-72.0] to 91.7 (IQR = 60.4-95.8, P < 0.0001), whereas mistriage decreased from 38.9 (IQR = 28.0-51.5) to 8.3 (IQR = 4.2-39.6, P < 0.0001), demonstrating a significant improvement in accuracy and decrease in mistriage. Screen-based simulation 60S is an effective modality for learning PDT by pediatric emergency nurses.

Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center.

OBJECTIVE: To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN: A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. RESULTS: A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. CONCLUSIONS: Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.

From Concept to Publication: Effectiveness of the International Network for Simulation-Based Pediatric Innovation, Research, and Education Project Development Process at Generating Simulation Scholarship.

BACKGROUND: As simulation matures, it is critical to develop pathways for researchers. A recent analysis, however, demonstrates a low conversion rate between abstract and peer-reviewed journal publication in our field. The International Network for Simulation-based Pediatric Innovation, Research, and Education has used the ALERT Presentation process for the past decade as a means of accelerating research. In this study, we analyze the scholarly products attributable to ALERT Presentations. METHODS: Surveys were distributed to all International Network for Simulation-based Pediatric Innovation, Research, and Education Advanced Look Exploratory Research Template (ALERT) Presentation first authors from January 2011 through January 2020. Presenters were asked to provide information on abstracts, grants, journal publications, and book chapters related to their ALERT Presentation, as well as basic demographic information. A structured literature search was conducted for those ALERT Presentations whose authors did not return a survey. The resulting database was descriptively analyzed, and statistical correlations between demographic variables and scholarship were examined. RESULTS: One hundred sixty-five new ALERT presentations were presented over 10 years. We identified 361 associated scholarly works (170 conference abstracts, 125 peer-reviewed journal publications, 65 grants, and 1 book chapter). Sixty-one percent (101 of 165) of ALERT Presentations produced at least 1 item of scholarship, and 59% (34 of 58) of ALERT Presentations that resulted in at least 1 abstract also led to at least 1 peer-reviewed journal article. Presenter gender was associated with likelihood of journal publication. CONCLUSIONS: The ALERT Presentation process is an effective approach for facilitating the development of projects that result in disseminated scholarship. Wider adoption may benefit other simulation and education research networks.

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.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND: The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training. METHODS: This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument. RESULTS: A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%). CONCLUSIONS: This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

Simulation Training for Community Emergency Preparedness.

Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [Pediatr Ann. 2021;50(1):e19-e24.].

Telementoring for remote simulation instructor training and faculty development using telesimulation.

Introduction: Simulation-based training is essential for high-quality medical care, but it requires access to equipment and expertise. Technology can facilitate connecting educators to training in simulation. We aimed to explore the use of remote simulation faculty development in Latvia using telesimulation and telementoring with an experienced debriefer located in the USA. Methods: This was a prospective, simulation-based longitudinal study. Over the course of 16 months, a remote simulation instructor (RI) from the USA and a local instructor (LI) in Latvia cofacilitated with teleconferencing. Responsibility gradually transitioned from the RI to the LI. At the end of each session, students completed the Debriefing Assessment for Simulation in Healthcare (DASH) student version form (DASH-SV) and a general feedback form, and the LI completed the instructor version of the DASH form (DASH-IV). Outcome measures were the changes in DASH scores over time. Results: A total of eight simulation sessions were cofacilitated of 16 months. As the role of the LI increased over time, the debrief quality measured with the DASH-IV did not change significantly (from 89 to 87), although the DASH-SV score decreased from a total median score of 89 (IQR 86-98) to 80 (IQR 78-85) (p=0.005). Conclusion: In this study, telementoring with telesimulations resulted in high-quality debriefing. The quality-perceived by the students-was higher with the involvement of the remote instructor and declined during the transition to the LI. This concept requires further investigation and could potentially build local simulation expertise promoting sustainability of high-quality simulation.

Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program.

OBJECTIVES: The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS: This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS: A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS: This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.