Improving Pediatric Procedural Skills for EMS Clinicians: A Longitudinal Simulation-Based Curriculum with Novel, Remote, First-Person-View Video-Based Outcome Measurement.

OBJECTIVE: Emergency medical services (EMS) clinicians are expected to provide expert care to all patients, but face obstacles in maintaining skillsets required in the care of critically ill or injured children. The objectives of this study were to describe and assess the effectiveness of a pediatric-focused, simulation-based, procedural training program for EMS clinicians, delivered on-site by a pediatric simulation education team. We also describe a novel, remote, asynchronous performance outcome measurement system using first-person-view video review. METHODS: This was a prospective study of simulation-based training and procedural outcomes. The study population involved EMS clinicians at three fire-based EMS agencies stratified as urban, suburban, and rural sites. The primary outcome was performance of intraosseous catheterization (IO), bag-valve-mask ventilation (BVM), and supraglottic device placement (SGD), measured across three time points. Secondary outcomes were identification of differences across EMS agencies and participant survey responses. RESULTS: We obtained video data from 122 clinicians, totaling 561 videos, with survey response rates of 89.0-91.3%. Pre-intervention scores were high: least-square means (95% confident-intervals) 9.5 (8.9, 10.2) for IO; 9.6 (9.3, 9.9) for BVM; and 11.6 (10.9, 12.2) for SGD. There was significant improvement post-intervention: 11.5 (10.7, 12.3) for IO; 11.0 (10.7, 11.4) for BVM; and 13.6 (12.8, 14.4) for SGD. Improvement was maintained at follow-up after a median of 9.5 months: 10.5 (9.8, 11.2) for IO; 10.2 (9.9, 10.6) for BVM; and 12.4 (11.7, 13.1) for SGD. There were no statistical differences between sites. Of survey respondents, half had not cared for a critically ill or injured child in at least a year, the vast majority had not had hands-on pediatric training in over 6 months, and the majority felt that training should occur at least every 6 months. CONCLUSIONS: Our pediatric-focused, simulation-based procedural training program was associated with improvement and maintenance of high-baseline procedural performance for EMS clinicians over the study period. Findings were consistent across sites. Remote assessment was feasible. Participant surveys emphasized a desire for more pediatric-focused training and highlighted the low frequency of clinical exposure to procedures potentially needed in the care of critically ill or injured pediatric patients.

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department.

OBJECTIVES: The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork. METHODS: This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool. RESULTS: We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007). CONCLUSIONS: Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

Video-Based Study of the Progression of Pediatric Emergency Medicine Fellows' Tracheal Intubation Performance During Training.

BACKGROUND: The lower clinical exposure of Pediatric Emergency Medicine (PEM) fellows to critical procedures may impede skill acquisition. We sought to determine the tracheal intubation learning curve of PEM fellows during training and compared PEM fellow success against standards for tracheal intubation success. METHODS: This was a retrospective, video-based study of a cohort of PEM fellows at a single academic pediatric emergency department (PED). All forms of tracheal intubation were included (rapid sequence intubation and crash or no medication). The cohort consisted of 36 PEM fellows from all or part of 5 consecutive fellowship classes. Data were collected by structured review of both existing ceiling-mounted videos and the electronic medical record. The main outcome was PEM fellows' success on the first or second attempt. We used cumulative summation to generate tracheal intubation learning curves. We specifically assessed the proportion of PEM fellows who reached 1 of 4 thresholds for procedural performance: 90% and 80% predicted success on the first and the first or second attempt. RESULTS: From July 2014 to June 2020, there were 610 patient encounters with at least 1 attempt at tracheal intubation. The 36 PEM fellows performed at least 1 attempt at tracheal intubation for 414 ED patient encounters (65%). Median patient age was 2.1 years (interquartile range, 0.4-8.1). The PEM fellows were successful on the first attempt for 276 patients (67%) and on the first or second attempt for 337 (81%). None of the 36 PEM fellows reached the 90% threshold for either first or second attempt success. Four fellows (11%) met the 80% threshold for first attempt success and 11 (31%) met the 80% threshold for first or second attempt success. CONCLUSIONS: Despite performing the majority of attempts, PEM fellows often failed to reach the standard thresholds for performance of tracheal intubation. Clinical exposure alone is too low to ensure acquisition of airway skills.

The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children.

STUDY OBJECTIVE: Our study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department. METHODS: We conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models. RESULTS: Proceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization-by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7). CONCLUSIONS: Emergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department.

ABSTRACT: Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

A Video-Based, Case-Control Study of Factors Associated With Intraosseous Catheterization During Pediatric Resuscitation.

STUDY OBJECTIVE: Factors associated with intraosseous (IO) catheterization are not well described. Our objective is to identify factors associated with the attempt and timing of IO catheterization in a pediatric emergency department (ED) resuscitation setting. METHODS: We completed a video-based, case-control study (1:3 ratio) of children undergoing IO catheterization in the resuscitation area of a high-volume, academic, pediatric ED. We selected 8 independent factors a priori for analysis: younger than 2 years, Glasgow Coma Scale score less than 8, cardiopulmonary resuscitation (CPR), parent or caregiver presence, physician team leader with greater than 5 years of pediatric ED experience, 2 or more IO-catheterization-capable staff, ultrasonographically trained nurse vascular access team presence, and resuscitation occurring during the evening (4 pm to midnight) or overnight (midnight to 8 am) shift. We fit linear regression models to analyze for associations with IO access attempts and timing. RESULTS: One hundred fourteen patients were enrolled; 40 encounters involved IO catheterization (35.1%). Only CPR was associated with IO catheterization (odds ratio 39.0; 95% confidence interval 12.5 to 121.6). Mean time to IO attempt was shorter with CPR (3.2 versus 14.2 minutes) and longer with vascular access team presence (23.5 versus 3.4 minutes) or caregiver presence (10.5 versus 2.6 minutes). Of resuscitations that achieved peripheral intravenous access, only 1 (1.1%) did so in less than 90 seconds. CONCLUSION: CPR was the only factor associated with IO access attempts, whereas providers may have been more hesitant to attempt IO catheterization with vascular access team or caregiver presence. Future studies should include a larger, multicenter sample and use qualitative methods to explore reasons for IO catheterization hesitancy, especially in the nonarrest scenario.

Resident Performance of the Rapid Cardiopulmonary Assessment in the Emergency Department.

OBJECTIVES: The rapid cardiopulmonary assessment (RCPA) is an essential first step in effective resuscitation of critically ill children. Pediatric residents may not be achieving competency with resuscitative skills, including RCPA. Our objective was to determine how often pediatric residents complete the RCPA for actual patients. METHODS: This was an observational, cross-sectional study of senior residents (≥postgraduate year 2) performing the RCPA in the resuscitation area of a high-volume pediatric emergency department (PED), where pediatric residents are expected to perform the bedside examination and assessment for all medical (nontrauma) patients. Data were collected primarily by video review on a standard form. The primary outcome was completion of the RCPA, defined as both examination and verbalized assessment of the airway, breathing, and circulation. We explored the association between RCPA completion and both residency year and number of previous PED rotations. RESULTS: Complete data were collected from one randomly selected patient for 71 (95%) of 75 of eligible senior residents who rotated in the PED between January and June 2013. Two residents (3%) performed a complete RCPA. Verbalized assessment of circulation was especially rare (7/71; 10%). There was no association between RCPA completion and year of training or previous PED experience (P > 0.05). CONCLUSIONS: Senior pediatric resident performance of the RCPA in the resuscitation area of a high-volume PED was poor. There was no association between RCPA completion and greater resident experience, including in the PED. These findings add to a growing body of literature suggesting that pediatric residents are not achieving competency with the RCPA and resuscitation skills.

Validity evidence for a team-leading assessment tool in pediatric emergency resuscitations using video review.

Background: Effective leadership of health care action teams has demonstrated positive influence on team performance and patient care, but there is no consensus on how to assess these skills. We developed a novel team leadership assessment tool for leaders of interprofessional pediatric resuscitation teams and collected validity evidence for this tool using video review. Methods: This was a prospective cohort study from November 2021 to October 2022. A novel team leadership assessment tool was developed using literature review and local expertise and then piloted and refined using medical simulation. Pediatric emergency medicine (PEM) fellows from a single tertiary care pediatric medical center were enrolled, and videos of one medical resuscitation and one trauma resuscitation were collected per fellow each month. Three reviewers underwent reviewer training and then scored the videos using the assessment tool. Raters provided feedback on feasibility and ease of use using a 5-point Likert scale. Inter-rater reliability for the assessment tool using Gwet's agreement coefficient and the association between performance and clinical level of training using generalized linear mixed model were calculated. Results: Twelve PEM fellows enrolled and 146 videos were reviewed. The inter-rater reliability for each domain ranged from 0.45 (p < 0.0001) to 0.59 (p < 0.0001), with the inter-rater reliability of the total score being 0.49 (p < 0.0001). The reviewers' mean ratings of the elements of the tool were as follows: clarity of the domains (4.6/5), the independence of each domain from each other (3.9/5), the ease of use of the 5-point Likert scale (4.5/5), the usefulness of the provided examples for each domain (4.6/5), and the ability to assess each domain without having to rewatch (4.5/5). The tool differentiated between levels of clinical training for two of the six domains (p < 0.02). Conclusions: We developed a novel team leadership assessment tool for pediatric resuscitation team leaders that demonstrated moderate inter-rater reliability. The tool was easy to use and feasible for educators to assess the performance of PEM trainees in complex high-stakes clinical situations.

Rapid cycle deliberate practice to improve airway skills and performance of trainees in a pediatric emergency department.

Objective: The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows. Methods: We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review). Results: During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p = 0.028) and shorter attempt duration (22 s vs. 29 s, p = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p = 0.231). Conclusions: At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows.

Multiuser immersive virtual reality simulation for interprofessional sepsis recognition and management.

INTRODUCTION: Sepsis is a leading cause of pediatric mortality. While there has been significant effort toward improving adherence to evidence-based care, gaps remain. Immersive multiuser virtual reality (MUVR) simulation may be an approach to enhance provider clinical competency and situation awareness for sepsis. METHODS: A prospective, observational pilot of an interprofessional MUVR simulation assessing a decompensating patient from sepsis was conducted from January to June 2021. The study objective was to establish validity and acceptability evidence for the platform by assessing differences in sepsis recognition between experienced and novice participants. Interprofessional teams assessed and managed a patient together in the same VR experience with the primary outcome of time to recognition of sepsis utilizing the Situation Awareness Global Assessment Technique analyzed using a logistic regression model. Secondary outcomes were perceived clinical accuracy, relevancy to practice, and side effects experienced. RESULTS: Seventy-two simulations included 144 participants. The cumulative odds ratio of recognizing sepsis at 2 min into the simulation in comparison to later time points by experienced versus novice providers were significantly higher with a cumulative odds ratio of 3.70 (95% confidence interval: 1.15-9.07, p = .004). Participants agreed that the simulation was clinically accurate (98.6%) and will impact their practice (81.1%), with a high degree of immersion (95.7%-99.3%), and the majority of side effects were perceived as mild (70.4%-81.4%). CONCLUSIONS: Our novel MUVR simulation demonstrated significant differences in sepsis recognition between experienced and novice participants. This validity evidence along with the data on the simulation's acceptability supports expanded use in training and assessment.

Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review.

ABSTRACT: This systematic review was performed to assess the effectiveness of in situ simulation education. We searched databases including MEDLINE and Embase for studies comparing in situ simulation with other educational approaches. Two reviewers screened articles and extracted information. Sixty-two articles met inclusion criteria, of which 24 were synthesized quantitatively using random effects meta-analysis. When compared with current educational practices alone, the addition of in situ simulation to these practices was associated with small improvements in clinical outcomes, including mortality [odds ratio, 0.66; 95% confidence interval (CI), 0.55 to 0.78], care metrics (standardized mean difference, -0.34; 95% CI, -0.45 to -0.21), and nontechnical skills (standardized mean difference, -0.52; 95% CI, -0.99 to -0.05). Comparisons between in situ and traditional simulation showed mixed learner preference and knowledge improvement between groups, while technical skills showed improvement attributable to in situ simulation. In summary, available evidence suggests that adding in situ simulation to current educational practices may improve patient mortality and morbidity.

The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view.

STUDY OBJECTIVE: We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED). METHODS: We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure. RESULTS: Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures. CONCLUSION: Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill.

Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.

BACKGROUND: Latent safety threats (LSTs) are errors in design, organization, training, or maintenance that may contribute to medical errors and have a significant impact on patient safety. The investigation described in this article was conducted as part of a larger prospective, longitudinal evaluation using laboratory- and in situ simulation-based training sessions to improve technical and nontechnical skills of neonatal ICU (NICU) providers at a Level III academic NICU. METHODS: Simulations were performed in laboratory (4 scenarios per session) and in situ (1 scenario per session) settings with multidisciplinary neonatology teams. Facilitators and subjects identified LSTs during standardized debriefings immediately following each scenario After enrollment, facilitators classified LSTs into equipment, medication, personnel, resource, or technical skill. Pervasive team knowledge gaps were further subclassified into lack of awareness or understanding, procedure performed incorrectly, omission of necessary action, or inappropriate action. RESULTS: In a 19-month period of enrollment (August 2009-March 2011), 177 subjects of 202 NICU providers were trained in the laboratory, 135 of whom participated in the in situ sessions. In the laboratory, 22 sessions were completed, with 70 LSTs identified (0.8 LSTs per scenario). During the 16 in situ sessions, 29 LSTs (1.8 LSTs per scenario) were identified. The 99 LSTs were reported to NICU leadership, leading to 19 documented improvements. CONCLUSIONS: The NICU setting has a high rate of previously unidentified LSTs. Conducting in situ scenarios allows for the identification of novel LSTs not detected in the simulation laboratory. The subsequent clinical improvements made to the actual clinical care environment are the best objective evidence of the benefits of simulation-based multidisciplinary team training.

Making a move: Using simulation to identify latent safety threats before the care of injured patients in a new physical space.

BACKGROUND: In today's rapidly changing health care environment, hospitals are expanding into newly built spaces. Preserving patient safety by identifying latent safety threats (LSTs) in advance of opening a new physical space is key to continued excellent care. At our level 1 pediatric trauma center, the hospital undertook a 5-year project to build a critical care tower, including a new emergency department with five trauma bays. To allow for identification and mitigation of LSTs before opening, we performed simulation-based clinical systems testing. METHODS: Eight simulation scenarios were developed, based on actual patient presentations, incorporating a variety of injury patterns. Scenarios included workflow and movement from the helipad and squad entrance as well as to radiology, the operating room, and the pediatric intensive care unit. A multiple resuscitation scenario was also designed to test the use of all five bays simultaneously. Multidisciplinary high-fidelity simulations were conducted in the new tower. Key trauma and emergency department stakeholders facilitated all sessions, using a structured framework for systems integration debriefing framework and failure mode and effect analysis to identify and prioritize LSTs, respectively. RESULTS: Eight sessions were conducted for 2 months. A total of 201 staff participated, including trauma surgeons, respiratory therapists, nurses, emergency physicians, x-ray technicians, pharmacists, emergency medical services, and operating room staff. In total, 118 LSTs (average of 14.8/session) were identified. Latent safety threats were categorized. An action plan for mitigation was developed after applying failure mode and effects analysis prioritization scores (based on severity, probability, and ease of detection). CONCLUSION: Systems-focused trauma simulations identified a large number of LSTs before the opening of a new critical care building. Identification of LSTs is feasible and facilitates mitigation before actual patient care begins, improving patient safety. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Tolerability and Acceptability of Autonomous Immersive Virtual Reality Incorporating Digital Twin Technology for Mass Training in Healthcare.

INTRODUCTION: As part of onboarding and systems testing for a clinical expansion, immersive virtual reality (VR) incorporating digital twin technology was used. While digital twin technology has been leveraged by industry, its use in health care has been limited with no prior application for onboarding or training. The tolerability and acceptability of immersive VR for use by a large population of healthcare staff were unknown. METHODS: A prospective, observational study of an autonomous immersive VR onboarding experience to a new clinical space was conducted from May to September 2021. Participants were healthcare staff from several critical care and acute care units. Primary outcomes were tolerance and acceptability measured by reported adverse effects and degree of immersion. Secondary outcomes were attitudes toward the efficacy of VR compared with standard onboarding experiences. RESULTS: A total of 1522 healthcare staff participated. Rates of adverse effects were low and those with prior VR experience were more likely to report no adverse effects. Odds of reporting immersion were high across all demographic groups, though decreased with increasing age. The preference for VR over low-fidelity methods was high across all demographics; however, preferences were mixed when compared with traditional simulation and real-time clinical care. CONCLUSIONS: Large-scale VR onboarding is feasible, tolerable, and acceptable to a diverse population of healthcare staff when using digital twin technology. This study also represents the largest VR onboarding experience to date and may address preconceived notions that VR-based training in health care is not ready for widespread adoption.

Just-in-Time, Just-in-Place Virtual Training in the Pediatric Emergency Department: A Novel Approach to Impact the Perfusion Exam.

Background: Early identification of shock is vital in decreasing morbidity and mortality in the pediatric population. Although residents are taught the perfusion portion of the rapid cardiopulmonary assessment at our institution, they perform it at the bedside with 8.4% completing 1 part of the assessment and 9.7% verbalizing their findings. Newer technologies, including virtual reality (VR), offer immersive training to close this clinical gap. Objective: To assess senior pediatric residents' performance of a perfusion exam and verbalization of their perfusion assessment following VR-based Just-in-Time/Just-in-Place (JITP) training compared to video-based JITP training. We hypothesized that JITP media training was feasible, and VR JITP was more effective than video-based training. Methods: Residents were randomized to VR or video-based training during shifts in the emergency department. Clinical performance was assessed by review of a video-recorded patient encounter using a standardized assessment tool and by an in-person, two question shock assessment. Residents completed a survey assessing attitudes toward their intervention at the time of training. Results: Eighty-five senior pediatric residents were enrolled; 84 completed training. Sixty-four (76%) residents had a patient encounter available for video review (VR 33; Video 31). Fourteen residents in the VR group (42.4%, 95% CI 25.5% to 60.8%) and 13 residents in the video group (41.9%, 95% CI 24.6% to 60.9%) completed a perfusion exam AND verbalized an assessment during their next clinical encounter (X2 p-value 1.00). Fifty-one of 64 residents (79.7%) completed the two-step shock assessment; 50 (98%) agreed with supervising physician's assessment. VR was rated more effective than reading, low-fidelity manikin, standardized patient encounters, traditional didactic teaching, and online learning. Video was rated more effective than online learning, traditional didactic teaching, and reading. Conclusion: Novel video and VR JITP perfusion exam and assessment trainings are impactful and well-received by senior pediatric residents.

High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence.

BACKGROUND: Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS: We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS: Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS: In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.

Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.

STUDY OBJECTIVE: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED). METHODS: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success. RESULTS: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. CONCLUSION: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

Assessment of factors associated with the delayed transfer of pediatric trauma patients: an emergency physician survey.

OBJECTIVES: The purpose of this study was to identify, among emergency department (ED) physicians, the potential barriers impacting the appropriate and timely transfer of injured children to pediatric trauma centers. METHODS: Surveys assessed pediatric trauma knowledge and experience, transfer and imaging decisions, and perceived barriers to patient transfer. Two scenarios were created; one with a child meeting the state trauma triage criteria and one who did not. In April 2010, 936 surveys were mailed to randomly selected ED physicians. Respondents could answer by mail or online until June 30, 2010. RESULTS: A total of 486 surveys were returned, and 109 were excluded, leaving 377 included in the study. A majority reported limited experience in the care of the critically ill child, with 93%, 99%, 99%, and 100% respectively, having performed less than 5 intubations, intraosseous line, central line, or chest tube placements in the last year. In the scenario in which the child met criteria to be transferred, 74% appropriately transferred the patient, whereas in the other scenario, 34% transferred the patient. As much as 56% of the respondents reported they would perform a head computed tomography before transfer, mainly to avoid missed injuries and medicolegal concerns. Among those who would not transfer either patient, 27% reported not having an on-call surgeon at all times. CONCLUSIONS: Innovative measures should be developed so that ED physicians gain a greater understanding of the proper identification of pediatric patients requiring a timely transfer to a pediatric trauma center.