Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network.

BACKGROUND: Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research. METHODS: In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations. RESULTS: Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic. CONCLUSIONS: Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice.

Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known: • Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures. • We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms "pediatrics," "hypnotics and sedatives," "conscious sedation," and "ambulatory surgical procedures" and the non-MeSH term "procedural sedation" and found no reports describing the current practice of pediatric PSA in Europe. What is New: • This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia. • Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.

Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Healthcare Providers: The Role of Simulation for Pandemics and Other Disasters.

OBJECTIVES: Early preparation for the training and education of healthcare providers, as well as the continuation or modification of routine medical education programs, is of great importance in times of the coronavirus disease 2019 pandemic or other public health emergencies. The goal of this study was to characterize these self-reported efforts by the pediatric simulation community. DESIGN: This was a global, multicenter survey developed via a Delphi process. SETTING: International survey study. SUBJECTS: The survey was sent to 555 individual members of the three largest international pediatric simulation societies (The International Pediatric Simulation Society, International Network for Simulation-based Pediatric Innovation, Research & Education, and Netzwerk Kindersimulation e.V.) between April 27, 2020, and May 18, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Description of coronavirus disease 2019 pandemic simulation-based preparation activities of pediatric acute and critical care healthcare providers. The Delphi process included 20 content experts and required three rounds to reach consensus. The survey was completed by 234 participants (42.2%) from 19 countries. Preparation differed significantly between the geographic regions, with 79.3% of Anglo-American/Anglo-Saxon, 82.6% of Indian, and 47.1% of European participants initiating specifically coronavirus disease 2019-related simulation activities. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued noncoronavirus disease 2019-related simulation training. CONCLUSIONS: The swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. The approach used, however, depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements.

Parental satisfaction with waiting time in a Swiss tertiary paediatric emergency department.

INTRODUCTION: Patient numbers in paediatric emergency departments (PED) are steadily increasing. Parental perception of waiting time and reasons for attending a PED with non-emergencies have been investigated in the UK, Australia, Korea, Canada and the USA. We sought to examine which factors influence parental satisfaction with waiting time in a tertiary Swiss PED and whether these differed from other countries. METHODS: Paper surveys were administered to parents of children presenting to our interdisciplinary PED from February to May 2015. Primary outcome was parental satisfaction with waiting time, secondary outcomes were satisfaction with treatment, parental reasons for presentation with non-emergencies, parental perception of times to triage, first physician contact and disposition from ED, level of physician training, understanding of various anticrowding strategies and comparison of perceived and true waiting times to triage and physician contact. RESULTS: 739 out of 750 surveys were returned (57 complete, 298 with 1 or 2 missing answers). Satisfaction with waiting time (on a 5-point-Likert-scale; 1 being the best possible answer) was higher in groups with shorter waiting time until triage (+0.41, p=0.001), first physician contact (+1.43, p<0.001) and discharge (+0.71, p<0.001), higher triage category urgency (+0.47, p=0.044) and available entertainment (+0.82, p<0.001). Early first physician contact (+0.33, p=0.008) and time to discharge less than 4 hours (+0.37, p<0.001) was associated with greater satisfaction with treatment (p<0.05). The most frequent reasons for presentation were parental impression that the child had an emergency (n=265, 35.9%) and referral by the family doctor (n=245, 33.2%). CONCLUSION: To counteract parental dissatisfaction associated with waiting time, we suggest the implementation of feasible measures including entertainment while waiting, early first medical review and timely discharge from the PED.

Balanced Electrolyte Solutions or Normal Saline? Resuscitative Fluid Administration Practice in Swiss Pediatric Acute Care: A Cross-Sectional Study.

INTRODUCTION: The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. AIM: We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. METHODS: For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. RESULTS: Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. CONCLUSION: There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.

Unique Presentation of Hematometrocolpos Mimicking Cauda Equina Syndrome: Severe Back Pain and Urinary Incontinence in an Adolescent Girl.

BACKGROUND: Imperforate hymen with hematometrocolpos in adolescent females is a rare pediatric condition. Classical presentation includes abdominal pain or a pelvic mass in female patients with primary amenorrhea. Atypical complaints and reluctance among emergency physicians to perform genital examination in the emergency department or the pediatric emergency department (PED) may delay correct diagnosis. CASE REPORT: We report a unique, cauda equina syndrome-like presentation of hematometrocolpos secondary to imperforate hymen in a 13-year old, previously healthy girl with primary amenorrhea. In the PED, the unusual clinical presentation of severe back pain and urinary incontinence initially mimicked cauda equina syndrome and led to delayed correct diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The novelty of this case is a cauda equina-like presentation of imperforate hymen secondary to hematocolpos. This report illustrates the highly variable clinical presentation of this rare gynecological pediatric entity. It underlines the importance of considering this rare condition in the differential diagnosis of severe upper or lower back pain alongside voiding abnormalities including urinary retention and incontinence in adolescent females with primary amenorrhea. Above all, the importance of performing a thorough history and genital examination in this subgroup early in the investigation process in the PED emerges from this case. Essentially, excellent clinical judgment and genital examination by the emergency physician may minimize unnecessary radiological investigations and ultimately, accelerate correct diagnosis and expedite appropriate surgical treatment. However, not only pediatric and adult emergency physicians, but also pediatricians and general practitioners should be aware of this entity and its diverse clinical presentation.

Nurses' and physicians' reported difficulties and enablers to recognising and reporting child abuse in Swiss paediatric emergency and paediatric surgery departments - an observational study.

BACKGROUND: Under-detection and under-reporting of child abuse remains a considerable challenge in paediatric care, with a high number of cases missed each year in Switzerland and abroad. Published data regarding the obstacles and facilitators of detecting and reporting child maltreatment among paediatric nursing and medical staff in the paediatric emergency department (PED) are scarce. Despite the existence of international guidelines, the measures taken to counteract the incomplete detection of harm done to children in paediatric care are insufficient. AIM: We sought to examine up-to-date obstacles and enablers for detecting and reporting child abuse among nursing and medical staff in PED and paediatric surgery departments in Switzerland. METHODS: We surveyed 421 nurses and physicians working in PEDs and on paediatric surgical wards in six large Swiss paediatric hospitals using an online questionnaire between February 1, 2017, and August 31, 2017. RESULTS: The survey was returned by 261/421 (62.0%) respondents (complete n = 200, 76.6%; incomplete n = 61, 23.3%) with a preponderance of nurses (n = 150/261; 57.5%), 106/261 (40.6%) physicians, and 1/261 (0.4%) psychologists (n = 4/261; 1.5% missing profession). The stated obstacles to reporting child abuse were uncertainty about the diagnosis (n = 58/80; 72.5%), feeling unaccountable for notification (n = 28/80; 35%), uncertainty of whether reporting has any consequences (n = 5/80; 6.25%), lack of time (n = 4/80; 5%), forgetting to report (n = 2/80; 2.5%), and parental protection (n = 2/80; 2.5%) (unspecific answer, n = 4/80; 5%, multiple answers were possible, therefore items don not sum up to 100%). Even though most (n = 249/261 95.4%) respondents had previously been confronted with child abuse at/outside work, only 185/245 (75.5%) reported cases; significantly fewer nursing (n = 100/143, 69.9%) than medical staff (n = 83/99, 83.8%) (p = 0.013). Furthermore, significantly more nursing (n = 27/33; 81.8%) than medical staff (n = 6/33; 18.2%) (p = 0.005) reported a discrepancy between the number of suspected and reported cases (total 33/245 (13.5%). An overwhelming amount of participants were strongly interested in mandatory child abuse training (n= 226/242, 93.4%) and in the availability of standardised patient questionnaires and documentation forms (n = 185/243, 76.1%). CONCLUSION: In line with previous studies, insufficient knowledge about and lack of confidence in detecting the signs and symptoms of child abuse were the principal obstacles to reporting maltreatment. To finally address this unacceptable gap in child abuse detection, we recommend the implementation of mandatory child protection education in all countries where no such education has been implemented in addition to the introduction of cognitive aid tools and validated screening tools to increase child abuse detection rates and ultimately prevent further harm to children.

Recommendations of the Netzwerk Kindersimulation for the Implementation of Simulation-Based Pediatric Team Trainings: A Delphi Process.

BACKGROUND: Serious or life-threatening pediatric emergencies are rare. Patient outcomes largely depend on excellent teamwork and require regular simulation-based team training. Recommendations for pediatric simulation-based education are scarce. We aimed to develop evidence-based guidelines to inform simulation educators and healthcare stakeholders. METHODS: A modified three-round Delphi technique was used. The first guideline draft was formed through expert discussion and based on consensus (n = 10 Netzwerk Kindersimulation panelists). Delphi round 1 consisted of an individual and team revision of this version by the expert panelists. Delphi round 2 comprised an in-depth review by 12 external international expert reviewers and revision by the expert panel. Delphi round 3 involved a revisit of the guidelines by the external experts. Consensus was reached after three rounds. RESULTS: The final 23-page document was translated into English and adopted as international guidelines by the Swiss Society of Pediatrics (SGP/SSP), the German Society for Neonatology and Pediatric Intensive Care (GNPI), and the Austrian Society of Pediatrics. CONCLUSIONS: Our work constitutes comprehensive up-to-date guidelines for simulation-based team trainings and debriefings. High-quality simulation training provides standardized learning conditions for trainees. These guidelines will have a sustainable impact on standardized high-quality simulation-based education.

An analysis of finger and hand injuries in children in a tertiary paediatric emergency department.

AIMS OF THE STUDY: This study set out to examine the association between current subspecialty (paediatric and hand surgery) consultation practice for children with hand and finger injuries presenting to a tertiary paediatric emergency department and length of stay in the paediatric emergency department. Also, incidence and injury pattern of hand and finger injuries in this patient group were analysed. METHODS: This was a retrospective cross-sectional study, which was undertaken as a clinical audit service. All patients under 17 years presenting to our paediatric emergency department with hand and finger injuries over a 17-month period were included in the analysis. We studied incidence and injury mechanism, current subspecialty referral practice, as well as paediatric emergency department and hospital length of stay. RESULTS: We identified 929 children for inclusion in the analysis. The most frequent reasons for presentation were hand contusions (25.5%) and fractures (20.8%). Paediatric emergency medicine physicians alone managed 845 patients (90.6%), paediatric surgery referral occurred in 50 (5.4%) and hand surgery consultation in 37 (4.0%) cases. Mean length of stay in the paediatric emergency department was 154 min and significantly longer when subspecialty review occurred. Hospital admission occurred in 87 cases (9.3%). CONCLUSIONS: Involvement of subspecialties in the care of hand and finger injuries was associated with significantly increased length of stay in the paediatric emergency department. We discuss obstacles and enablers for timely patient referral and management. We suggest the implementation of referral guidelines, tailored to the individual emergency department, to reduce unnecessary patient journey delays and to ensure higher quality repair of complex hand injuries by the appropriate surgeon, with better outcomes. Making use of the emergence of multiple surgical subspecialties for targeted treatment of paediatric finger and hand injuries might be desirable.

Intravenous chlorpromazine for acute paediatric migraine.

OBJECTIVE: In paediatric migraine, ibuprofen, acetaminophen and triptans are safe, effective therapies but there is scant paediatric data informing second-line emergency treatment. METHODS: Retrospective cohort study of children diagnosed with migraine at a tertiary children's hospital ED. RESULTS: There were 207 children with migraine over a 1 year period. 46% received simple oral analgesia. 25% intravenous chlorpromazine, of whom 45% received further analgesia. CONCLUSIONS: While intravenous chlorpromazine as second-line agent was mostly safe, it had unclear efficacy given the requirement for further treatment and hospital admissions.

Avatar and distance simulation as a learning tool - virtual simulation technology as a facilitator or barrier? A questionnaire-based study on behalf of Netzwerk Kindersimulation e.V.

Background: Virtual simulation modalities have been implemented widely since the onset of the severe acute respiratory syndrome coronavirus 2 pandemic restrictions in March 2020, as educators face persistent restrictions to face-to-face education of medical students and healthcare professionals.There is paucity of published data regarding the benefits and barriers of distance and avatar simulation training modalities. Methods: Following a 2-day virtual pediatric simulation competition facilitated by Netzwerk Kindersimulation e.V., using remote human avatars and distance simulation, we conducted a multicenter survey to explore the advantages and challenges of avatar and distance simulation among participants. We used a modified Delphi approach to draft and develop the 32-item online questionnaire with 7-point Likert-like scales (7 being the highest rating). Results: Twenty participants answered our questionnaire. Respondents indicated both a high overall satisfaction (median of 5.0 [Q25-Q75: 4.0-6.0] ) for avatar and distance simulation 6.0 (5.0-6.0), respectively, as well as a high achieved psychological safety with both simulation types (5.0 [4.0-6.0] vs. 5.0 [4.0-6.0]). The most frequently reported profits of avatar and distance simulation included the elimination of travel distances, associated lower costs, less time spent attending the education activity, and effective communication and leadership training, especially with avatar simulation. Most often named challenges were technical problems, limited reception of non-verbal cues and a spatial distance from the team/educator. Discussion: Based on the results of this pilot study, avatar and distance simulation can be employed successfully and appear to be good supplements to face-to-face simulation. Other studies are warranted to further explore the effectiveness of various types of virtual simulation compared to conventional presential simulation. We suggest using avatar-based simulation for targeted communication and leadership skills training and the application of distance simulation to bring simulation experts virtually to remote places where educator resources are lacking.

Aplasia cutis congenita in surviving co-twin after propylthiouracil exposure in utero.

AIM: Aplasia cutis congenita (ACC) has been observed after fetal exposure to the antithyroid drug methimazole (MMI), but not reported after propylthiouracil (PTU), the current antithyroid drug of choice during pregnancy. This occurrence has implications for patient information and causal research. CASE REPORT: We describe a surviving term co-twin to a mother with hyperthyroidism exposed to PTU from conception to 34 weeks of gestation presenting with ACC at birth. DISCUSSION: The association between PTU exposure and ACC is clinically relevant and allows speculation on the etiology. A similar mechanism to the classical MMI-induced ACC is postulated, unless a vascular etiology suggested by a vanishing twin or maternal hyperthyroidism itself is causal. Coincidence of PTU exposure and ACC seems unlikely. CONCLUSION: ACC in a newborn after PTU exposure during pregnancy hitherto observed only after MMI strongly encourages further reports of similar cases that may remain clinically underdiagnosed or unreported. Such confirmation could have significant implications for maternal treatment of hyperthyroidism, common in women of childbearing age.

The erroneous perception of a clinical sign: Cholestasis preceding sepsis mimicking hepatitis in an adolescent patient.

Jaundice should be considered as a first clinical sign preceding severe invasive bacterial infection or sepsis in patients of all ages including childhood and adolescence. Early laboratory investigations and MR imaging studies for osteomyelitis or myositis are paramount to avoid progression to life-threatening sepsis and significant morbidity and mortality.

Adverse events and risk factors during emergency intubation in a tertiary paediatric emergency department.

BACKGROUND: Rapid sequence intubation and emergency intubation in the emergency department (ED) can be life-saving procedures, but require the appropriate skills, experience and preparation to avoid complications ranging from simple trauma to life-threatening desaturation. Only scarce data exist in the published literature on complications following emergency intubation in children and most guidelines are extrapolated from the adult population. PATIENTS AND METHODS: We reviewed all emergency intubations of patients in our tertiary paediatric ED within a 2-year period to estimate the incidence of complications and to analyse the risk factors associated with this procedure. RESULTS: Seventy-two children were intubated; complications occurred in one in four and repeated attempts at intubation in 17/23 children. The median age of the children was 2 years (range: 0 days-6 years). The most common reason for intubation was altered level of consciousness and the most frequent diagnosis at the time of intubation was seizure/status epilepticus. Complications were related to desaturation (n=7), equipment failure (n=3), intravenous access (n=2) and hypotension (n=2), erroneous or insufficient drug preparation (n=1) and other reasons (n=3). There was no significant association of complications with the child's age or weight, time of arrival to ED, preintubation hypotension or combination of drugs used. CONCLUSION: Complications of rapid sequence intubation, a relatively low-frequency procedure in the paediatric ED, occurred in one of four children and repeat attempts at intubation were made in another 24%. We suggest that the use of an intubation checklist including the preparation of equipment and recommendations for drug use would minimize the occurrence of adverse events of intubation in children.

Status Quo in Pediatric and Neonatal Simulation in Four Central European Regions: The DACHS Survey.

INTRODUCTION: Simulation has acquired wide acceptance as an important component of education in health care and as a key tool to increase patient safety. This study aimed at identifying to what extent and how pediatric and neonatal simulation-based training (SBT) was being carried out in four Central European regions. METHODS: We surveyed all pediatric and neonatal health care institutions in Germany, Austria, Switzerland, and South Tyrol on their current state of SBT using an online questionnaire. RESULTS: We dispatched 440 questionnaires with a 45.9% response rate. Sixty-one percent (61.4%) of institutions performed SBT (algorithm training, 87.4%; skill training, 62.2%; high-fidelity SBT, 56.8%). Training was conducted interprofessionally at 88.9% of surveyed institutions. Physicians and nurses most often received SBT once per year. Lack of financial (62.2%) and personnel (54.1%) resources were the most frequent impediments to establish SBT. CONCLUSIONS: Although delivered heterogeneously, widespread use of pediatric simulation and a considerable number of already existing SBT programs are the key findings of this survey. These data are encouraging enough to promote more effective networking in simulation-based research, education, training, and quality improvement, as we aim to ultimately increase patient safety for neonates, infants, and children.

Health and Medicine in the Future: Change through Sports Medicine - Sports Medicine in Change / Salud y Medicina en el futuro: Cambio a través de la medicina deportiva - Medicina deportiva en el cambio

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