Advances in Pediatric Telehealth Education and Training: A National Survey.

Background: The COVID-19 pandemic accelerated the formal integration of telehealth into education curricula and training programs, prompting the need to reevaluate the current landscape and inform a research agenda. We developed a survey to assess telehealth education and training curriculum, competencies, certification, and research across pediatric medical centers. Methods: Questions were derived from a previously published national survey and de novo. The survey was distributed across national pediatric professional associations. Results: In total, 32 respondents representing medical centers (86.5%) were providing telehealth education and/or training. Most were internally developed didactic (78.6%) and experiential (64.3%) curricula. Respondents who included education and/or training in telehealth research protocols and conducted telehealth research (74%) reported mandatory or optional training in tele-research. A form of certification was preferred by most organizations (>60%). Conclusion: Telehealth education and training are key factors within current and future service development, provision, and research to demonstrate competencies and positively impact patient care.

Pediatric Telehealth Access and Utilization in Chicago During the First Year of the COVID-19 Pandemic.

Background: The COVID-19 pandemic demanded rapid development of telemedicine services for pediatric care and highlighted disparities for marginalized communities. Objective: To understand the demographic characteristics of patients with completed and incomplete telemedicine visits at Ann and Robert H. Lurie Children's Hospital of Chicago. Methods: This was a cross-sectional retrospective analysis of telemedicine visits for patients <25 years old scheduled between March 21, 2020, and March 17, 2021. We examined visit outcomes and compared outcomes by race/ethnicity, language, and payer using logistic regression. Geographic information system mapping and linear regression were used to examine the relationship between incomplete visits and broadband access within Cook County. Results: A total of 13,655 eligible video visits were scheduled for children within 147 ZIP codes during the study time frame. Patient characteristics included median age 9 years, 53% female, 42% non-Latinx White, 31% Latinx, 13% non-Latinx Black, 11% non-Latinx other, and 3% declined/unknown. Preferred language was 89% English, 10% Spanish, and 1% other. Payer was 56% private, 43% public, and <1% other/self-pay. Overall, 86% video visits were completed, 7% cancelled, and 7% no-show with significant variation by patient demographic. Odds of incomplete visits were higher for Latinx patients (odds ratio [OR] 1.93) and non-Latinx Black patients (OR 2.33) than for non-Latinx White patients, patients with preferred language other than English (OR 1.53), and patients not privately insured (OR 1.89). Incomplete visit rates and broadband access were inversely related. Conclusion: System and policy solutions are needed to ensure equitable access and address disparities in incomplete telemedicine visits for marginalized populations in urban areas with lower broadband.

A Brief, Just-in-Time Sedation Training in the Pediatric Emergency Department Improves Performance During Adverse Events Encountered in Simulated Procedural Sedations.

BACKGROUND: Procedural sedation (PS) is commonly performed in emergency departments (EDs) by nonanesthesiologists. Although adverse events (AEs) are rare, providers must possess the clinical skills to react in a timely manner. We previously described residents' experience and confidence in PS as part of a needs assessment. We found that their ability to perform important clinical tasks as a result of the usual training experience demonstrates educational needs. We developed an educational intervention to address the deficiencies uncovered during our needs assessment. OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' clinical performance and confidence when faced with an AE during a simulated PS. METHODS: This was a prospective observational cohort study of residents at a tertiary care children's hospital. All ED attending physicians and fellows were trained in uniform delivery of the educational intervention, which was delivered extemporaneously at the bedside ("Just-in-Time" [JIT]) to all residents performing PS on actual patients in the pediatric ED, over the course of 1 year. Subjects completed the following both before and after the educational intervention: a survey pertaining to confidence in PS, followed by a standardized, video-recorded simulated PS complicated by apnea and desaturation. Clinical performance was evaluated and assessed both in real time and by a video-rater blinded to participants' year of training. We summarized baseline resident characteristics, confidence questionnaire item rankings and success in both the preparation and AE tasks. We compared successful task completion and time to task completion before and after intervention. RESULTS: Forty residents completed both the PRE and POST phases of the study. There was significant improvement in the proportion of residents who completed both preparation and AE tasks after the JIT training. Specifically, there was a significant improvement in the proportion of residents who performed positive-pressure ventilation to treat an apneic event associated with desaturation during the PS (P = 0.007). Residents' confidence scores also significantly improved after the training. CONCLUSION: A brief JIT training in the pediatric ED improves resident clinical performance and confidence when faced with an AE during a simulated PS. Future direction includes correlating this improved performance with patient outcomes in PS.

Children's Hospital Transfers From Referring Emergency Departments: Which Patients Bypassed the Pediatric Emergency Department?

OBJECTIVES: Children are increasingly transferred from emergency departments (EDs) to children's hospitals for inpatient care. The existing literature on the use of direct admission (DA) specifically among pediatric patients transferred from referring EDs remains sparse.The objective of this study was to identify demographic, clinical, and contextual factors associated with the use of direct-to-inpatient versus ED-to-inpatient admission among patients transferred to children's hospitals from EDs. METHODS: This was a retrospective chart review of nontrauma patients admitted to inpatient services at a single tertiary children's hospital after interfacility transfer from EDs between July 1, 2016, and June 30, 2017. Characteristics of the patient population and referring EDs were described; unadjusted associations between rates of DA and the demographic, clinical, and contextual variables of encounters were performed; and a logistic model quantified the relevant associations as odds ratios (ORs). RESULTS: Of 2939 study encounters, 78% resulted in DA. Among White patients, private insurance was associated with decreased direct admission (OR, 0.5; 95% confidence interval [CI], 0.4-0.8). Younger patients and patients with respiratory diagnoses (OR, 3.9; 95% CI, 2.8-5.3) had increased likelihood of DA. Patients with gastrointestinal diagnoses had decreased likelihood of DA (OR, 0.6; 95% CI, 0.4-0.7). CONCLUSIONS: At a tertiary hospital with a high rate of DA among patients transferred from other EDs, we identified factors that were associated with the use of direct versus ED admission. Our results identify specific populations in which future work could inform admission processes for interfacility transfers.

Telehealth Utilization in Response to the COVID-19 Pandemic: Current State of Medical Provider Training.

Background: The COVID-19 pandemic accelerated the development of telehealth services and thus the need for telehealth education and training to support rapid implementation at scale. A national survey evaluating the current state of the telehealth landscape was deployed to organizational representatives, and included questions related to education and training. Materials and Methods: In the summer of 2020, 71 survey participants (31.8%) completed an online survey seeking to determine the utilization of telehealth services across institutional types and locations. This included data collected to specifically compare the rates and types of formal telehealth education provided before and during the pandemic. Results: Thirty percent of organizations reported no telehealth training before COVID-19, with those in suburban/rural settings significantly less likely to provide any training (55% vs. 82%) compared with urban. Pandemic-related training changes applied to 78% of organizations, with more change happening to those without any training before COVID-19 (95%). Generally, organizations offering training before the pandemic reported deploying COVID-19-related telehealth services, while a higher percentage of those without any training beforehand reported that they either did not plan on providing these services or were in the early planning stages. Discussion: Telehealth education is moving from elective to essential based on the need to prepare and certify the workforce to support high-quality telehealth services. Conclusions: As telehealth continues to evolve to meet the future health care service needs of patients and providers, education and training will advance to meet the needs of everyday clinical encounters and broader public health initiatives.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE: To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN: Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS: Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS: Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Integrated Multimodality Telemedicine to Enhance In-Home Care of Infants During the Interstage Period.

Performing interstage home monitoring using digital platforms (teleIHM) is becoming commonplace but, when used alone, may still require frequent travel for in-person care. We evaluated the acceptability, feasibility, and added value of integrating teleIHM with synchronous telemedicine video visits (VVs) and asynchronous video/photo sharing (V/P) during the interstage period. We conducted a descriptive program evaluation of patient-families receiving integrated multimodality telemedicine (teleIHM + VV + V/P) interstage care from 7/15/2018 to 05/15/2020. First, provider focus groups were conducted to develop a program logic model. Second, patient characteristics and clinical course were reviewed and analyzed with univariate statistics. Third, semi-structured qualitative interviews of family caregivers' experiences were assessed using applied thematic analysis. Within the study period, 41 patients received teleIHM + VV + V/P care, of which 6 were still interstage and 4 died. About half (51%) of patients were female and 54% were a racial/ethnic minority. Median age was 42 days old (IQR 25, 58) at interstage start, with a median of 113 total days (IQR 72, 151). A total of 551 VVs were conducted with a median 12 VVs (IQR 7, 18) per patient. Parents sent a median 2 pictures (IQR 0-3, range 0-82). Qualitatively, families reported an adjustment period to teleIHM, but engaged favorably with telemedicine overall. Families felt reassured by the oversight routine telemedicine provided and identified logistical and clinical value to VVs above teleIHM alone, while acknowledging trade-offs with in-person care. Integration of multimodality telemedicine is a feasible and acceptable approach to enhance in-home care during the interstage period.

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation.

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2-5) to 6 (IQR 4-7) following SST (p < 0.0009, median difference 2, 95% CI 1-3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

Assessing pediatric residents' clinical performance in procedural sedation: a simulation-based needs assessment.

OBJECTIVES: Our primary objective in this study was to perform a needs assessment of clinical performance during simulated procedural sedation (PS) by pediatric residents. Our secondary objective was to describe reported experience and confidence with PS during pediatric residency. METHODS: In this prospective observational cohort study, pediatric residents completed a survey of 15 Likert-scaled items pertaining to confidence in PS, followed by performance of a standardized, video-recorded simulated PS complicated by an adverse event (AE): apnea and desaturation. Clinical performance was evaluated according to an expert consensus-derived checklist of critical tasks. The difference in reported confidence between postgraduate years (PGY) was assessed by one-way analysis of variance (ANOVA); clinical checklist items were quantified descriptively. RESULTS: A total of 35 PGY-1, 39 PGY-2, and 7 PGY-3 residents participated. The most frequently completed tasks by all residents are ensuring the cardiorespiratory monitor (73%) and connecting the oxygen tubing (70%) during the preparation phase and recognizing AE (97%) and administering oxygen (95%) during the AE phase. Tasks that were completed infrequently by all residents include ensuring that the shoulder roll is available (11%) and ensuring access to head-of-bed (31%) during the preparation phase and applying shoulder roll (10%) and calling for help (23%) during the AE phase. The median time to recognition of AE from onset of hypoventilation was 33 seconds and that for delivery of oxygen and PPV was 60 and 97 seconds, respectively. Median confidence scores increased by PGY (PGY-1, 2; PGY-2, 3; PGY-3, 4; ANOVA F2,82 = 75, P< 0.0001). CONCLUSIONS: Significant differences exist in the reported confidence and observed performance among PGY levels during simulated PS. Resident performance on this checklist demonstrates educational needs in PS training. A curriculum in PS for pediatric residents should focus on reviewing preparation steps, equipment, and potential interventions should an AE occur.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics.

In this article, we provide an overview of remote monitoring of pediatric PGHD and family-generated health data, including its current uses, future opportunities, and implementation resources.

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training.

PURPOSE: To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees. METHODS: We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training. RESULTS: Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier. CONCLUSIONS: Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.

Cholelithiasis in a toddler with sickle cell disease.

Cholelithiasis is rarely seen in toddlers and school-aged children, even in the setting of sickle cell anemia. In addition to more common etiologies, such as gastroenteritis, constipation, and urinary tract infection, the differential diagnoses of acute abdominal pain in young children with sickle cell disease include vaso-occlusive pain crisis and splenic sequestration. We describe a case of a toddler with sickle cell disease initially presenting with abdominal pain who was found to have symptomatic cholelithiasis.

Ectopic atrial tachycardia in an infant with transient erythroblastopenia of childhood.

Transient erythroblastopenia of childhood is a self-limited anemia occurring in previously healthy children, secondary to temporary cessation of erythrocyte production. Although the precise etiology is unclear, most cases are associated with a viral illness. The anemia may be severe, with associated pallor, tachypnea, and tachycardia; treatment is supportive. We present an unusual case of a child with viral-induced transient erythroblastopenia of childhood and associated ectopic atrial tachycardia, requiring therapy with antiarrhythmics.

Attitudes and Perceptions of Telemedicine in Response to the COVID-19 Pandemic: A Survey of Naïve Healthcare Providers.

Introduction: Expansion of telemedicine enabled healthcare access during the COVID-19 pandemic. In response to in-person visit restrictions, our institution trained >1,000 clinicians in telemedicine. Little is known about telemedicine-naïve pediatric healthcare provider's perceptions as they adopted telemedicine practice. Methods: We conducted a cross-sectional survey of clinicians after expanding telemedicine practice at an independent children's hospital. The survey assessed experience with, concerns about, and intentions to continue telemedicine. Outpatient providers were included if they were first trained for telemedicine in response to COVID-19 and conducted at least one video visit, 3/21/2020-6/30/2020. Descriptive statistics were calculated; perceptions were compared across telemedicine activity level quartiles (based on proportions of visits delivered by video in June 2020) using Fisher's exact tests. Results: Of 609 survey responses, 305 (50.1%) met inclusion criteria, representing various roles and disciplines. Over half (54.1%) conducted >20 video visits 3/21/2020-6/30/2020. More than 75% of providers found telemedicine easy to learn. Providers with greater proportions of video visits in a typical week in June reported greater ease of incorporating telemedicine into clinical practice and greater intention to continue telemedicine practice in 6 months. Nearly all providers endorsed concerns. Patient care experiences reinforced technology-related concerns and alleviated liability and privacy concerns. Payer reimbursement was the leading influencer of anticipated future use of telemedicine. Discussion: Providers who conducted more telemedicine encounters reported greater ease of incorporating telemedicine into practice. Provider concerns were influenced by patient care experiences. Targeted training and quality improvement strategies are needed to sustain a robust post-pandemic telemedicine program.

One-Size-Fits All: A Scalable Solution to Formal Telemedicine Provider Training to Support the COVID-19 Pandemic Response.

Introduction: Formalized training in telemedicine addresses barriers to provider adoption and engagement and assures a level of competence for independent practice. We previously developed a blended-model training program, customizable according to role and specialty; this method of training was not feasible in the pandemic response. We describe the development and implementation of a multi- and interdisciplinary telemedicine provider training program enabling the rapid scaling of telemedicine at our institution. Methods: An existing curriculum was pared down to a 1-h session delivered synchronously, covering the foundational components of telemedicine practice. Supplemental materials were available for asynchronous learning via the hospital intranet. Completion of training was required of all clinicians who practice telemedicine. Results: We conducted 35 sessions for 1,070 providers over 12 weeks. Attendees included clinicians across numerous roles and specialties. Additional resources were created and available through the Telemedicine Virtual Handbook and housed in specific toolkits. Discussion: Telemedicine training is necessary for consistent, competent practice of telemedicine in pediatrics. We describe a training process that can be easily replicated and rapidly deployed to providers of telemedicine across roles and disciplines. Combining a mandatory and brief synchronous provider training session with a repository of online resources creates a foundation for consistent practice, while allowing for more individualized resources accessible on demand. Standardized telemedicine training followed by mechanisms for ongoing professional practice evaluation allow institutions to ensure consistent and competent practice of telemedicine. Further study is needed to determine the best modality for training, and optimal assessment tools according to professional role.

Telehealth in pediatric emergency medicine.

Modern technologies and contemporary clinical practice have set the stage for the integration of telehealth into existing models of healthcare. These models of telehealth care offer novel opportunities for advancing pediatric emergency care. In this manuscript, we introduce applications of telehealth in pediatric emergency medicine (PEM) with the pediatric emergency department (ED) both as originating site and distant site. We present barriers to adoption, implementation, and sustaining PEM telehealth programs, as well as strategies to overcome those. We discuss cost and finances as well as policy considerations and implications. Lastly, we review strategies for evaluation to assess program impact and ensure sustainability.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

Spontaneous gastric perforation in a child with heterotaxy syndrome.

Gastric perforation is a potentially fatal condition that is rare in infants and children. Most case reports in the pediatric population are of neonates or in patients with various associated risk factors including prematurity, ischemia, trauma, or ulcers. Heterotaxy syndrome is characterized by abnormal symmetry and malposition of the thoracoabdominal organs and vessels. Spontaneous gastric perforation has not previously been reported in a child with heterotaxy syndrome. We present a case of a child with heterotaxy syndrome who presented with spontaneous gastric perforation. We review the signs and the symptoms, radiographic clues, and diagnostic considerations of gastric perforation.

Emergency Care Connect: Extending Pediatric Emergency Care Expertise to General Emergency Departments Through Telemedicine.

Increasingly, children with common and lower-acuity conditions are being transferred from general emergency departments (EDs) to pediatric centers for subspecialty care. While transferring children with high-risk conditions has benefit, transferring children with common conditions may expose them to redundant care and added costs. Emergency Care Connect (ECC) is a novel telemedicine program that uses videoconferencing to connect general ED and urgent care providers to pediatric emergency medicine physicians with the goal of keeping children in their communities for definitive care, when safe and feasible. ECC objectives are to: 1) facilitate transfer decision-making for children receiving care in general ED and urgent care sites and 2) increase access to pediatric providers for real-time management, regardless of disposition. In its first 20 months, ECC partnered with 4 general EDs and 1 urgent care location, which together made 1327 contacts with our pediatric center, of which 202 (15%) became ECC consultations for 200 unique patients. Of those consultations, 71% patients remained locally for treatment and 25% experienced a care plan change. Overall, ECC was rated highly by surveyed families and providers. Barriers to implementation, such as lack of familiarity with telemedicine and fears of changes in workflow, were overcome with strong institutional support and frequent, sustained stakeholder engagement. With greater adoption of this model, ECC and programs like it have the potential to allow more children to be treated in their communities, minimize preventable transfers, and reserve beds in children's hospitals for those with potentially higher risk and more medically complex conditions.