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In this article, we describe the development and assessment of a 2-year longitudinal quality improvement (QI) and patient safety curriculum that matches didactic education with experiential learning in a pediatric emergency medicine fellowship. The curriculum includes the development of a comprehensive didactic series and an improvement project identified, designed, and implemented by the fellows. The curriculum was assessed through a questionnaire administered before and after participation in the curriculum, along with an evaluation of the clinical impact of the completed project and assessment of a scholarly product. There was an increase in comfort with QI tools including run and control charts and in familiarity with differences between QI and traditional clinical research after completion of the QI curriculum. Fellows agreed that QI would be beneficial to their careers and felt that they were more likely to be involved in a future QI project. The fellow-derived project was integrated into QI efforts within the emergency department and results showed improvement in process outcomes. In summary, a longitudinal QI curriculum combining didactic and project-based learning in a pediatric emergency medicine fellowship was successful in increasing fellow comfort with QI tools and led to a successfully implemented collaborative improvement project.

Gaining facility in pediatric advanced airway management is challenging. Inherent differences in the pediatric airway anatomy as well as the relative infrequency of clinical opportunities to develop these complex psychomotor skills are contributing factors. Videolaryngoscopy offers both technical and educational advantages over direct laryngoscopy. Data are emerging to support its growing use in emergency medicine. This review summarizes the relevant evidence regarding video laryngoscopy in emergent pediatric intubation. In addition, practical tips for the safe and effective use of 3 pediatric devices are provided.

Over the last few decades, we have seen significant changes in the approach to improving health care. During the 1990s, we witnessed the integration of evidence-based practice into medicine. The concept of applying rigorous and reliable evidence from high-quality research studies to improve clinical practice quickly spread across disciplines. Explanations behind medical decision making now regularly include phrases like “the data would suggest...” and “there is evidence to support...” More recently, quality improvement and patient safety have become the popular buzzwords in medicine. Again a new lexicon has emerged in conversations, the literature, and at academic meetings. Terms like control charts, plan-do-study-act cycle, root cause analysis, and high-reliability organizations are increasingly populating medical dialogue. Although there is a rigorous science to the process of quality improvement, the basic premise is to develop “systematic and continuous actions that lead to measurable improvement in health care services.” Advanced airway management is well suited for quality improvement initiatives. Available data suggest that first-pass success rates during emergency pediatric intubations are as low as 37% for pediatric trainees in the intensive care unit setting and as high as 78% for pediatric emergency medicine providers (including trainees and faculty) in a pediatric ED. There is a well-described association between repeated attempts and adverse events. Therefore, given the relatively low firstpass success rate in pediatrics, it is no surprise that reported adverse event rates are high—up to 61%

Although emergency department procedural sedation in children is widely practiced, it is not without risk. Appropriate vital sign monitoring has been identified as an essential mechanism to reduce risk associated with procedural sedation. We describe the evolution of guidelines for procedural sedation monitoring in children and review monitoring principles, common adverse events, current monitoring modalities, future directions, and emerging monitoring technologies.

Children with respiratory diseases present commonly to the emergency department. As a continuous, dynamic measure of the ventilatory status, capnography can provide valuable information in the assessment and management of these patients. After a review of the relevant physiology and technology of carbon dioxide monitoring, clinical applications for the use of capnography in patients with respiratory illnesses are discussed. Characteristic waveforms are provided, and their interpretation and clinical significance are discussed. A focus on the current literature investigating the noninvasive monitoring of patients with obstructive lung disease is included. Practical tips for successfully using capnography are also presented.

Capnography provides continuous, dynamic assessment of the ventilatory status of patients. Carbon dioxide physiology and the technology utilized in end-tidal carbon dioxide monitor devices are reviewed. Clinical applications with regard to ventilation and airway management are discussed, including: verification of endotracheal tube placement, continuous monitoring of tube position, monitoring during procedural sedation and in the obtunded patient, and assessment of patients with respiratory illnesses. Current guidelines for use of capnography within emergency medicine are included. Potential future applications are also presented.

The practice of procedural sedation and analgesia in pediatrics is evolving rapidly. Some of our practices are backed by substantial supporting data, whereas for others, the evidence base is less well developed, leading to substantial differences in provider preferences. In addition, the multidisciplinary nature of providing sedation and differences in local custom and regulatory requirements all contribute to a certain amount of practice variability: the “art” of sedation. To provide a forum for exploring this, we invited experts in pediatric procedural sedation to share their practices and “pearls”, combining anecdotal experience with evidence from the literature.