Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.

Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.

Pediatric anesthesiology fellow education: is a simulation-based boot camp feasible and valuable?

BACKGROUND: Pediatric anesthesiologists must manage crises in neonates and children with timely responses and limited margin for error. Teaching the range of relevant skills during a 12-month fellowship is challenging. An experiential simulation-based curriculum can augment acquisition of knowledge and skills. OBJECTIVES: To develop a simulation-based boot camp (BC) for novice pediatric anesthesiology fellows and assess learner perceptions of BC activities. We hypothesize that BC is feasible, not too basic, and well received by fellows. METHODS: Skills stations, team-based in situ simulations, and group discussions of complex cases were designed. Stations were evaluated by anonymous survey; fellows rated usefulness in improving knowledge, self-confidence, technical skill, and clinical performance using a Likert scale (1 strongly disagree to 5 strongly agree). They were also asked if stations were too basic or too short. Median and interquartile range (IQR) data were calculated and noted as median (IQR). RESULTS: Fellows reported the difficult airway station and simulated scenarios improved knowledge, self-confidence, technical skill, and clinical performance. They disagreed that stations were too basic or too short with exception of the difficult airway session, which was too short [4 (4-3)]. Fellows believed the central line station improved knowledge [4 (4-3)], technical skills [4 (4-4)], self-confidence [4 (4-3)], and clinical performance [4 (4-3)]; scores trended toward neutral likely because the station was perceived as too basic [3.5 (4-3)]. An interactive session on epinephrine and intraosseous lines was valued. Complicated case discussion was of educational value [4 (5-4)], the varied opinions of faculty were helpful [4 (5-4)], and the session was neither too basic [2 (2-2)] nor too short [2 (2-2)]. CONCLUSION: A simulation-based BC for pediatric anesthesiology fellows was feasible, perceived to improve confidence, knowledge, technical skills, and clinical performance, and was not too basic.

Leveraging Health Care Simulation Technology for Human Factors Research: Closing the Gap Between Lab and Bedside.

OBJECTIVE: We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery. BACKGROUND: The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care. METHOD: Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium. RESULTS: Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning. CONCLUSION: The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency. APPLICATION: Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery.

A randomized, controlled trial of in situ pediatric advanced life support recertification ("pediatric advanced life support reconstructed") compared with standard pediatric advanced life support recertification for ICU frontline providers*.

OBJECTIVE: Recent evidence shows poor retention of Pediatric Advanced Life Support provider skills. Frequent refresher training and in situ simulation are promising interventions. We developed a "Pediatric Advanced Life Support-reconstructed" recertification course by deconstructing the training into six 30-minute in situ simulation scenario sessions delivered over 6 months. We hypothesized that in situ Pediatric Advanced Life Support-reconstructed implementation is feasible and as effective as standard Pediatric Advanced Life Support recertification. DESIGN: A prospective randomized, single-blinded trial. SETTING: Single-center, large, tertiary PICU in a university-affiliated children's hospital. SUBJECTS: Nurses and respiratory therapists in PICU. INTERVENTIONS: Simulation-based modular Pediatric Advanced Life Support recertification training. MEASUREMENTS AND MAIN RESULTS: Simulation-based pre- and postassessment sessions were conducted to evaluate participants' performance. Video-recorded sessions were rated by trained raters blinded to allocation. The primary outcome was skill performance measured by a validated Clinical Performance Tool, and secondary outcome was behavioral performance measured by a Behavioral Assessment Tool. A mixed-effect model was used to account for baseline differences. Forty participants were prospectively randomized to Pediatric Advanced Life Support reconstructed versus standard Pediatric Advanced Life Support with no significant difference in demographics. Clinical Performance Tool score was similar at baseline in both groups and improved after Pediatric Advanced Life Support reconstructed (pre, 16.3 ± 4.1 vs post, 22.4 ± 3.9; p < 0.001), but not after standard Pediatric Advanced Life Support (pre, 14.3 ± 4.7 vs post, 14.9 ± 4.4; p =0.59). Improvement of Clinical Performance Tool was significantly higher in Pediatric Advanced Life Support reconstructed compared with standard Pediatric Advanced Life Support (p = 0.006). Behavioral Assessment Tool improved in both groups: Pediatric Advanced Life Support reconstructed (pre, 33.3 ± 4.5 vs post, 35.9 ± 5.0; p = 0.008) and standard Pediatric Advanced Life Support (pre, 30.5 ± 4.7 vs post, 33.6 ± 4.9; p = 0.02), with no significant difference of improvement between both groups (p = 0.49). CONCLUSIONS: For PICU-based nurses and respiratory therapists, simulation-based "Pediatric Advanced Life Support-reconstructed" in situ training is feasible and more effective than standard Pediatric Advanced Life Support recertification training for skill performance. Both Pediatric Advanced Life Support recertification training courses improved behavioral performance.

Videolaryngoscopy versus direct laryngoscopy in simulated pediatric intubation.

STUDY OBJECTIVE: We determine whether videolaryngoscopy results in a higher prevalence of first-attempt intubation success and improved glottic visualization than direct laryngoscopy when performed by pediatric emergency medicine providers in simulated patients. METHODS: This was a cross-sectional study at a single institution. Fellows and faculty in pediatric emergency medicine were invited to participate. Each subject performed intubations on 3 simulators (newborn, infant, adult), using a videolaryngoscope; each simulator was intubated by each subject with and without use of video. Primary outcome was first-attempt intubation success; secondary outcome was percentage of glottic opening score (POGO). RESULTS: Twenty-six participants performed 156 intubations; complete data were available for 148 intubations. First-attempt success in the neonate was 88%; in the infant, 79%; and in the adult, 60%. In the adult simulator, videolaryngoscopy use showed a first-attempt success in 81% of subjects compared with 39% with direct laryngoscopy (difference 43%; 95% confidence interval [CI] 18% to 67%). There was no difference in first-attempt success rates between videolaryngoscopy and direct laryngoscopy in the newborn or infant simulators. Videolaryngoscopy use led to increased POGO scores in all 3 simulators, with a difference of 25% (95% CI 2% to 48%) in newborn simulators, 23% (95% CI 2% to 48%) in infant simulators, and 42% (95% CI 18% to 66%) in adult simulators. CONCLUSION: Videolaryngoscopy was associated with greater first-attempt success during intubation by pediatric emergency physicians on an adult simulator. POGO score was significantly improved in all 3 simulators with videolaryngoscopy.

Assessment of technique during pediatric direct laryngoscopy and tracheal intubation: a simulation-based study.

OBJECTIVES: This study aimed to assess the feasibility of characterizing direct laryngoscopy (DL) and tracheal intubation (TI) technique based on videographic review and to determine the association between technical aspects of DL and TI with successful completion of intubation. METHODS: Physicians in pediatrics, emergency medicine, pediatric emergency, pediatric critical care, and neonatology performed TI on simulators (newborn, infant, and adult). A video laryngoscope was used without a display (ie, as a direct laryngoscope), and video recordings were reviewed. A scoring instrument characterized technical aspects of DL and TI; outcomes related to procedural performance were recorded. Interrater reliability of the instrument was assessed by weighted κ; collinearity was assessed by a correlation matrix. Univariate analysis determined technical aspects of DL and TI associated with outcomes. RESULTS: Seventy-three subjects performed 206 intubations. Significant differences existed between simulators with respect to the first-attempt success (newborn, 63%; infant, 80%; adult, 42%; P < 0.001), laryngoscopy time (27 seconds vs 31 seconds vs 42 seconds, P < 0.001), and percentage of glottic opening score (68% vs 65% vs 35%, P < 0.001). Interrater reliability for the instrument was good (κ = 0.68); no significant collinearity existed between data points. Position of the tip of the laryngoscope blade in the vallecula and under the proximal epiglottis was associated with improved first-attempt success. CONCLUSIONS: Pediatric intubation technique can be reliably assessed using videography and video laryngoscopy. Future studies should examine video-based characterization of DL and TI technique in real patients outside the operating room, as well as whether technical aspects of intubation are associated with improved outcomes.

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.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation.

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Simulathon 2020: Integrating Simulation Period Prevalence Methodology Into the COVID-19 Disaster Management Cycle in India.

SUMMARY STATEMENT: The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon , with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India.

Introduction: Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings. Materials and Methods: We conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room. Results: There was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05). Conclusion: Telesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

Tracking manikin tracheal intubation using motion analysis.

OBJECTIVES: This study investigates whether laryngoscope motion-tracking technology can be used to differentiate expert versus novice providers' techniques during endotracheal intubation in infant manikins; this may help improve intubation techniques. METHODS: Each of 11 experts and 11 novices intubated an infant manikin head (Laerdal Corp, Wappinger Falls, NY) 10 times. Laryngoscope motion was tracked using electromagnetic technology during: (1) time from acquisition of laryngoscope to oral insertion, (2) insertion to stabilization of laryngoscope, and (3) stabilization of laryngoscope to insertion of endotracheal tube and withdrawal of laryngoscope. There were 213/220 analyzable data files. Expert versus novice rate of success, laryngoscope blade-tip motion path length, handle angle at intubation, time in each phase, and motion of handle relative to manikin were compared. RESULTS: Intubation success rate was greater for experts (105/105 = 100% vs novices 101/108 = 93.5%, P < 0.001). Expert path of motion in phase 2 was longer (mean, 39 vs 29 cm, P < 0.001). The mean difference in the laryngoscope handle angle relative to the manikin occiput was statistically significant (mean angle, -54.42 vs -56.63 degrees; P = 0.001) but within the equipment testing margin of error (2 degrees). Time from insertion to withdrawal of laryngoscope (phases 2 and 3 combined) was greater for experts (16.45 vs 13.15 seconds; P = 0.02). Both experts and novices "rocked" the laryngoscope to achieve laryngeal visualization. CONCLUSIONS: It is feasible to track laryngoscope motion during manikin intubation comparing expert versus novice technique. Experts had a greater success rate, but longer path length, and took longer to achieve manikin intubation. Motion-tracking technology may provide an analytic tool to improve techniques of intubation.

Regionalization of ORL Boot Camps: Report of the Society of University Otolaryngologists Task Force.

OBJECTIVES: Simulation-based boot camps have emerged as timely vehicles to help novice residents develop the skills needed to manage medical emergencies. Geographically regional boot camps provide opportunities for interaction between residents and faculty from multiple otolaryngology programs. The Society of University Otolaryngologists (SUO) Boot Camp Task Force investigated the concept of regional access to otolaryngology boot camps with the goal of making more regional boot camps available for otolaryngology residents across the United States. STUDY DESIGN: Interviews. METHODS: The SUO Boot Camp Task Force assessed regional access to otolaryngology boot camps with a focus on geographic distribution, curricular content, and finances. Boot camp directors were contacted by email and telephone and interviewed to elicit information on all these areas. RESULTS: Data were available from 10 known regional simulation-based boot camps designed for novice residents. Individual boot camps included from 12 to 30 residents and 10 to 50 faculty members. Curricula included both technical (ie, procedural) and non-technical (eg, communication, leadership) skills for individuals and teams. Content was heavily weighted toward a variety of airway problems and management techniques, although various conditions involving hemorrhage, and airway fires were also addressed. Funding and expense structures had the greatest variability. CONCLUSIONS: Considerable variability was identified among the known regional boot camps in terms of numbers of participants and finances, but fewer differences in curriculum. Geographic opportunity for 9 to 10 new boot camps was identified. The SUO Task Force recommends that a consensus be developed for several individual skill and teamwork scenario objectives to be included in each boot camp. Laryngoscope, 131:737-743, 2021.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Tracheostomy: pediatric considerations.

Pediatric patients for whom tracheotomy is a consideration have different anatomy, medical conditions, and prognoses than adults; even the tracheotomy tubes are different. Indications for pediatric tracheotomy generally include bypassing airway obstruction, providing access for prolonged mechanical ventilation, and facilitating tracheobronchial toilet. Subglottic stenosis is an important indication for tracheotomy in children; its etiology, prevention, and alternative options for management are presented. Discussion includes the benefits, risks, impact on families, techniques for tracheotomy tube changes, and alternatives to tracheotomy, with illustrative photographs and diagrams.

A Road Map for Simulation Based Medical Students Training in Pediatrics: Preparing the Next Generation of Doctors.

Current Medical training in India is generally didactic and pedagogical, and often does not systematically prepare newly graduated doctors to be competent, confident and compassionate. After much deliberation, the Medical Council of India (MCI) has recently introduced a new outcome-driven curriculum for undergraduate medical student training with specific milestones and an emphasis on simulation-based learning and guided reflection. Simulation-based education and debriefing (guided reflection) has transformed medical training in many countries by accelerating learning curves, improving team skills and behavior, and enhancing provider confidence and competence. In this article, we provide a broad framework and roadmap suggesting how simulation-based education might be incorporated and contextualized by undergraduate medical institutions, especially for pediatric training, using local resources to achieve the goals of the new MCI competency-based and simulation-enhanced undergraduate curriculum.

Do Fellows and Faculty Share the Same Perception of Simulation Fidelity? A Pilot Study.

INTRODUCTION: Simulation is increasingly integrated into graduate medical education, and simulation faculty generally attempt to optimize the fidelity of simulators and simulations on behalf of trainees, so as to approach the realism of actual patient care experiences. As residents and fellows participate as learners in simulations, which faculty design, this investigation sought to address whether fellows and faculty have similar perceptions of fidelity by comparing ratings of 2 types of simulation experiences. METHODS: Prospective single-center observational study comparing surveys completed by fellows and faculty participating in multiple simulation sessions during a one-day simulation-based boot camp. RESULTS: Overall, both the fellows and the faculty provided moderate to high ratings of fidelity for both a technical skill and a teamwork simulation session. Fellows' ratings of an airway skills session were significantly higher than faculty ratings in 4 of 6 questions but similar to faculty ratings of a teamwork scenario session. CONCLUSIONS: Pediatric anesthesia fellows' ratings of simulation fidelity were at least as high as faculty ratings during an annual boot camp, suggesting that faculty in this setting developed simulations that the fellows found to be realistic. Faculty were relatively more critical of the fidelity of a skill session, compared with a teamwork scenario session. If this finding is generalizable, this may reassure faculty designing simulations for fellows. Continued inspection of the entwined nature of fidelity and simulation will help inform more effective learning for this growing educational modality.

SimTube: A National Simulation Training and Research Project.

OBJECTIVE: To test the feasibility and impact of a simulation training program for myringotomy and tube (M&T) placement. STUDY DESIGN: Prospective randomized controlled. SETTING: Multi-institutional. SUBJECTS AND METHODS: An M&T simulator was used to assess the impact of simulation training vs no simulation training on the rate of achieving competency. Novice trainees were assessed using posttest simulator Objective Structured Assessment of Technical Skills (OSATS) scores, OSATS score for initial intraoperative tube insertion, and number of procedures to obtain competency. The effect of simulation training was analyzed using χ2 tests, Wilcoxon-Mann-Whitney tests, and Cox proportional hazards regression. RESULTS: A total of 101 residents and 105 raters from 65 institutions were enrolled; however, just 63 residents had sufficient data to be analyzed due to substantial breaches in protocol. There was no difference in simulator pretest scores between intervention and control groups; however, the intervention group had better OSATS global scores on the simulator (17.4 vs 13.7, P = .0003) and OSATS task scores on the simulator (4.5 vs 3.6, P = .02). No difference in OSATS scores was observed during initial live surgery rating (P = .73 and P = .41). OSATS scores were predictive of the rate at which residents achieved competence in performing myringotomy; however, the intervention was not associated with subsequent OSATS scores during live surgeries (P = .44 and P = .91) or the rate of achieving competence (P = .16). CONCLUSIONS: A multi-institutional simulation study is feasible. Novices trained using the M&T simulator achieved higher scores on simulator but not initial intraoperative OSATS, and they did not reach competency sooner than those not trained on the simulator.

Saving Lives and Improving the Quality of Pediatric Resuscitation Across the World: A 1-Day Research Accelerator Hosted by the International Network for Simulation-based Pediatric Innovation, Research, and Education and the International Pediatric Simulation Society.

STATEMENT: The International Network for Simulation-based Pediatric Innovation, Research, and Education co-hosted a novel research accelerator meeting with the International Pediatric Simulation Society in May of 2019 in Toronto. The purpose of the meeting was to bring together healthcare simulation scientists with resuscitation stakeholders to brainstorm strategies for accelerating progress in the science of saving pediatric lives from cardiac arrest. This was achieved by working in teams to draft targeted requests for proposals calling the research community to action investigating this topic. During the 1-day meeting, groups were divided into 6 teams lead by experts representing specific domains of simulation research. Teams developed a pitch and presented a sample request for proposals to a panel of expert judges, making a case for why their domain was the most important to create a funding opportunity. The winner of the competition had their specific request for proposal turned into an actual funding opportunity, supported by philanthropy that was subsequently disseminated through International Network for Simulation-based Pediatric Innovation, Research, and Education as a competitive award. An inspired donor supported an award for the second-place proposal as well, evidence of early research acceleration catalyzed from this conference. This article is a summary of the meeting rationale, format, and a description of the requests for proposals that emerged from the meeting. Our goal is to inspire other stakeholders to use this document that leverages simulation and resuscitation science expertise, as the framework to create their own funding opportunities, further accelerating pediatric resuscitation research, ultimately saving the lives of more children worldwide.

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.