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Supplemental digital content is available in the text., Objectives Capnography has established benefit during intubation and cardiopulmonary resuscitation (CPR). Implementation within emergency departments (EDs) has lagged. We sought to address barriers to improve documented capnography use for patients requiring intubation or CPR. Methods A controlled before- and after-implementation study was performed in 2 urban EDs. The control site had an existing policy for capnography use. Interventions for the experimental site included a 5-minute informational video, placement of capnography monitors with a shortened warm-up period in all resuscitation rooms, laminated reminder cards, and feedback during staff meetings. Staff members were surveyed about knowledge before and after the intervention. Records were reviewed for documented capnography use for 3 months before and 6 months after the intervention. Change in documented use at the experimental site was compared with the control site. Results At the experimental site, 118 providers participated and 190 records were reviewed; 544 records were reviewed from the control site. There was a significant increase in the proportion of documented capnography use at the experimental site (8% versus 19%, P = 0.04) compared with the control site (64% versus 71%, P = 0.10). However, there was no significant trend over time at the experimental site after the intervention (P = 0.86). Despite high baseline knowledge about capnography, providers had improvements in survey responses regarding indications for intubation and CPR, normal values, and minimum effective values during CPR. Conclusions Documented capnography use increased with simple interventions but with no positive trend. Additional work is needed to improve use, including further evaluation of capnography’s implementation in the ED.

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INTRODUCTION Healthcare providers' anthropometric characteristics can adversely affect adult cardiopulmonary resuscitation (CPR) performance quality. However, their effects on infant CPR are unknown. We aimed to determine any relationships between healthcare provider characteristics (anthropomorphic, demographics, training, occupational data) and simulated infant CPR performance at multiple international sites. Our secondary aim was to examine provider's CPR performance degradation. METHODS Providers from 4 international hospitals performed 2 minutes of single-rescuer simulated infant CPR using 2015 American Heart Association Basic Life Support criteria with guidance from a real-time visual performance feedback device. Providers' characteristics were collected, and the simulator collected compression and ventilation data. Multivariate analyses examined the entire 2 minutes and performance degradation. RESULTS Data from 127 participants were analyzed. Although median values for all compression variables (depth, rate, lean) and ventilation volume were within guideline target ranges, when looking at individuals, only 52% chest compressions and 20% ventilations adhered to the American Heart Association guidelines. Age was found to be independently associated with ventilation volume (direct-relationship), and height was associated with chest compression lean (shorter participant-deeper lean). No significant differences were noted based on sex or body mass index. Neonatal intensive care unit participants were noted to perform shallower chest compressions (P < 0.001). Overall, there was minimal evidence of performance degradation over 2 minutes. CONCLUSIONS Isolated provider characteristics were noted among a diverse cohort of healthcare providers that may affect the CPR quality on a simulated infant. Understanding the relationships between provider characteristics and CPR quality could inform future infant CPR guidelines customized for the provider and not just the patient.

The aim of this study was to describe our expansion of a Massachusetts grassroots initiative-to increase the appointment of pediatric emergency care coordinators (PECCs) in emergency departments (EDs)-to all 6 New England states.We conducted annual surveys of all EDs in New England from 2015 to 2020 regarding 2014 to 2019, respectively. Data collection included ED characteristics. The intervention from 2018 to 2019 relied on principles of self-organization and collaboration with local stakeholders including state Emergency Medical Services for Children agencies, American College of Emergency Physician state chapters, and Emergency Nursing Association state chapters to help encourage appointment of at least 1 PECC to every ED. Most ED leadership were contacted in person at regional meetings, by e-mail and/or telephone. We reached out to each individual ED to both educate and encourage action.Survey response rates were greater than 85% in all years. From 2014 to 2016, less than 30% of New England EDs reported a PECC. In 2017, 51% of EDs in New England reported a PECC, whereas in 2019, 91% of New England EDs reported a PECC. All other ED characteristics remained relatively consistent from 2014 to 2019.We successfully expanded a Massachusetts grassroots initiative to appoint PECCs to all of New England. Through individual outreach, and using principles of self-organization and creating collaborations with local stakeholders, we were able to increase the prevalence of PECCs in New England EDs from less than 30% to greater than 90%. This framework also led to the creation of a New England-wide PECC network and has fostered ongoing collaboration and communication throughout the region.

The health care sector has made radical changes to hospital operations and care delivery in response to the coronavirus disease (COVID-19) pandemic. This article examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the COVID-19 era. First, patient safety is enhanced through development and testing of new technologies, equipment, and protocols using laboratory-based and in situ simulation. Second, population health is strengthened through virtual platforms that deliver telehealth and remote simulation that ensure readiness for personnel to deploy to new clinical units. Third, prevention of lost revenue occurs through usability testing of equipment and computer-based simulations to predict system performance and resilience. Finally, simulation supports health worker wellness and satisfaction by identifying optimal work conditions that maximize productivity while protecting staff through preparedness training. Leveraging simulation and human factors will support a resilient and sustainable response to the pandemic in a transformed health care landscape.

Background: Limited early results indicate that the COVID-19 outbreak has had a significant impact on the mental health of children and adolescents. Pediatric emergency departments (PED) play a pivotal role in the identification, treatment, and coordination of care for children with mental health disorders, however, there is a dearth of literature evaluating the effects of the COVID-19 pandemic on mental health care provision in the PED. Objectives: We sought to evaluate whether changes in frequency or patient demographics among children and adolescents presenting to the PED has occurred. Methods: This is a cross-sectional study conducted at the Yale New Haven Children’s Hospital (YNHCH) PED. Data representing the early COVID-19 pandemic period was abstracted from the electronic medical record and compared using descriptive statistics to the same time period the year prior. Patient demographics including patient gender, ED disposition, mode of arrival, race-ethnicity, and insurance status were assessed. Results: During the pandemic period, 148 patients presented to the YNHCH PED with mental health-related diagnoses, compared to 378 in the pre-pandemic period, a reduction of 60.84%. Compared to white children, black children were 0.55 less likely to present with a mental health condition as compared to the pre-pandemic study period ( p = 0.002; 95% CI 0.36–0.85). Conclusions: Children with mental and behavioral health disorders who seek care in PEDs may be at risk for delayed presentations of mental health disorders. African American children may be a particularly vulnerable population to screen for mental health disorders as reopening procedures are initiated and warrants further study.

OBJECTIVES/INTRODUCTION: The Association of American Medical Colleges suggested that medical students not be involved in direct patient care activities in the United States because of the COVID pandemic. Our objectives are to (1) describe the rapid creation and implementation of a fully online simulation-based pediatric emergency medicine training intervention for medical student learners using existing simulation center staff (faculty, technicians, actors) and resources (simulation technology, scenario files) and (2) report student and faculty feedback on the intervention. METHODS: The sessions involved the use of our existing simulation center faculty, staff, and resources. Feedbacks on the sessions were collected via a survey from faculty and students at the end of each session. RESULTS: Sixteen simulation sessions were conducted (8 febrile infant, 8 anaphylactic toddler). Forty-eight students, 2 technicians, 2 actors, and 10 faculty participated. Ninety percent of the students agreed with the statements, "I am more comfortable with pediatrics after this session," "participating improved my pediatric knowledge/skills," "this session was more useful than other learning activities I am involved in at this time." Seventy percent of the students agreed with the statement, "I learned as much from observing as when I was actively involved." All faculty agreed with the statement, "this was an effective educational strategy compared to other distance learning." Most faculty (60%) disagreed with the statement, "virtual simulation was equal to or superior to in-person simulation." All students and faculty strongly agreed with the statement, "I would highly recommend this to others." CONCLUSIONS: A telesimulation intervention involving all medical students, staff, and facilitators interacting remotely for pediatric emergency training during COVID was associated with high levels of satisfaction by the majority of learners and faculty.

Though family satisfaction with prehospital care is a surrogate for quality and patient outcomes, there are no tools available to measure family satisfaction.To develop the EMS Family Assessment of Medical InterventionsLiaisons with the Young (FAMILY) instrument.Components of family experiences with pediatric prehospital care were identified with a modified Delphi method. The expert panel included Emergency Medical Technicians, paramedics, family representatives, and EMS leaders from Colorado, Connecticut, and Rhode Island. An online survey was used to assess proposed questions from each of five candidate domains from national guidelines, including Safety, Communication, Family Presence, Cultural Awareness, Children with Special Healthcare Needs and Overall Satisfaction. Round-1 items were scored on a five-point Likert scale. Inclusion in the final instrument required 70% agreement ranking items as "There were 22 experts in Round-1, and 20 continued into Round-2 .The Delphi process yielded 12 questions in six domains with 14 recommended modifications. Two questions were excluded. Five domains reached 70% agreement in Round-1. Cultural Awareness reached 75% agreement after Round-2. Six FAN representatives evaluated Version-1, leading to changes for clarity, content and cultural sensitivity. Seventeen FAN representatives evaluated Version-2 leading to additional refinement. The assessment of the equivalence between the English and Spanish survey versions resulted in changes in the Spanish language content for equivalent meaning.A panel of EMS and family stakeholders successfully developed an instrument to assess family satisfaction with pediatric EMS care. Further validation is required in a large respondent population. Assessing family satisfaction with pediatric EMS encounters is an important step toward improving prehospital care.

OBJECTIVES Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children

Introduction : Emergencies in the pediatric primary care office are high-risk, low-frequency events that offices may be ill-prepared to manage. We developed an intervention to improve pediatric primary care office emergency preparedness involving a baseline measurement, a customized report out with action plans for improvement (based on baseline measures), and a plan to repeat measurement at 6 months. This article reports on the baseline measurement.\ud Methods: This baseline measurement consisted of 2 components: preparedness checklists and in situ simulations. The preparedness checklists were completed in person to measure compliance with the American Academy of Pediatrics Policy Statement: preparation for emergencies in the offices of pediatricians and pediatric primary care providers, in the domains of equipment, supplies, medication, and guidelines. Two in situ simulations, a child in respiratory distress and a child with a seizure, were conducted with the offices' interprofessional teams; performance was scored using checklists.\ud Results : Baseline measurements were conducted in 12 pediatric offices from October to December 2018. Wide variability was noted for compliance with the American Academy of Pediatrics recommendations (range = 47%–87%) and performance during in situ simulations (range = 43%–100%).\ud Conclusions : Pediatric primary care office emergency preparedness was found to be variable. Simulation can be used to augment existing measures of emergency preparedness, such as checklists. By using simulation to measure office emergency preparedness, areas of knowledge deficit and latent safety threats were identified and are being addressed through ongoing collaboration.

BACKGROUND: Best practices for benchmarking the efficacy of simulation-based training programs are not well defined. This study sought to assess feasibility of standardized data collection with multicenter implementation of simulation-based training, and to characterize variability in pediatric trauma resuscitation task completion associated with program characteristics. METHODS: A prospective multicenter observational cohort of resuscitation teams (N = 30) was used to measure task completion and teamwork during simulated resuscitation of a child with traumatic brain injury. A survey was used to measure center-specific trauma volume and simulation-based training program characteristics among participating centers. RESULTS: No task was consistently performed across all centers. Teamwork skills were associated with faster time to computed tomography notification (r = −0.51, p < 0.01). Notification of the operating room by the resuscitation team occurred more frequently in in situ simulation than in laboratory-based simulation (13/22 versus 0/8, p < 0.01). CONCLUSIONS: Multicenter implementation of a standardized pediatric trauma resuscitation simulation scenario is feasible. Standardized data collection showed wide variability in simulated resuscitation task completion.

Introduction Simulation-based training is essential for high-quality medical care, but it requires access to equipment and expertise. Technology can facilitate connecting educators to training in simulation. We aimed to explore the use of remote simulation faculty development in Latvia using telesimulation and telementoring with an experienced debriefer located in the USA. Methods This was a prospective, simulation-based longitudinal study. Over the course of 16 months, a remote simulation instructor (RI) from the USA and a local instructor (LI) in Latvia cofacilitated with teleconferencing. Responsibility gradually transitioned from the RI to the LI. At the end of each session, students completed the Debriefing Assessment for Simulation in Healthcare (DASH) student version form (DASH-SV) and a general feedback form, and the LI completed the instructor version of the DASH form (DASH-IV). Outcome measures were the changes in DASH scores over time. Results A total of eight simulation sessions were cofacilitated of 16 months. As the role of the LI increased over time, the debrief quality measured with the DASH-IV did not change significantly (from 89 to 87), although the DASH-SV score decreased from a total median score of 89 (IQR 86–98) to 80 (IQR 78–85) (p=0.005). Conclusion In this study, telementoring with telesimulations resulted in high-quality debriefing. The quality—perceived by the students—was higher with the involvement of the remote instructor and declined during the transition to the LI. This concept requires further investigation and could potentially build local simulation expertise promoting sustainability of high-quality simulation.

Cognitive appraisal of stress can influence performance. Increased awareness could facilitate titration to optimal stress levels. This study’s primary aim was to investigate whether physiologic variables change with increasingly stressful simulations. Secondary aims include effect of stress on procedural competency and whether individuals recognize their experienced stress. This was a single-center, mixed-method, simulation-based study. Participants completed three scenarios requiring resuscitation under increasingly stressful conditions. Wearable biometric devices recorded physiologic parameters. Subjects completed surveys assessing knowledge and perceived stress. Intubation success or failure was noted. Heart rate variability (HRV) analysis was used as a proxy for stress. Twelve participants completed the study. Survey analysis revealed progressive amplification of endorsement of affective states associated with stress. Median low frequency (LF)/high frequency (HF) ratio from scenario 1 (median = 2.29, IQR = 1.97, 3.91) was significantly lower than scenario 2 (median = 4.7, IQR = 2.32, 8.35, p = 0.04) and scenario 3 (median = 4.63, IQR = 2.2, 7.43, p = 0.04). Changes in HRV were noted during all scenarios irrespective of subjective self-assessment of stress. Procedural proficiency suffered during more stressful scenarios. This study demonstrates alterations in subjective assessment and objective physiologic data in simulations with increasing stress. HRV is useful as a proxy for stress response and does not always correlate with perception.

Introduction: Previous research has described technical aspects of telemedicine and the clinical impact of provider-to-patient telemedicine; however, little is known about provider-to-provider telemedical interventions. Objective: The primary aim of this study was to compare two telemedicine delivery modes on the quality of a simulated neonatal resuscitation. Our secondary aim was to evaluate the providers’ task load. Methods: This was a prospective, single-center, randomized, simulation-based trial comparing a remote neonatal team leader (“teleleader”) versus a remote consultant (“teleconsultant”). Participants resuscitated a simulated, apneic, and bradycardic neonate. Performance was assessed by video review and task load was measured by the self-reported NASA task load index (NASA-TLX) tool. In the teleleader group, one remote neonatal specialist assumed the role of team leader in the resuscitation. In the teleconsultant group, the same remote specialist assumed the role of teleconsultant. Results: Twenty-two participants were included in the analyses. The teleleader group was associated with a higher overall checklist score compared to teleconsultants (median score 68%, interquartile range [IQR]: 66–69 vs. 58%, IQR: 42–62; p = 0.016). No significant difference was seen in overall subjective workload as measured by the NASA-TLX tool. However, mental demand and frustration were significantly greater with teleconsultants compared to teleleaders (mean mental demand: 14.1 vs. 17.0 out of 21; frustration: 7.9 vs. 14.7 out of 21). Conclusions: Simulated neonates randomized to teams with teleleaders received significantly better resuscitative care compared to those randomized to teams with teleconsultants. Mental demand and frustration were higher for providers in the teleconsultant compared to teleleader teams.

OBJECTIVES Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. METHODS We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. RESULTS Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. CONCLUSIONS Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

This cross-sectional study explores the use of physical restraint on youth at risk of harming themselves or others in the emergency department, stratified by race and ethnicity.

Rattlesnake envenomation is an uncommon but urgent cause of presentation for emergency care. Recognition of envenomation, timely administration of antivenom when indicated, and recognition of antivenom reactions are of critical importance to mitigate the local, hematologic, and systemic effects of Crotaline venom. This technical report describes the presentation and use of a simulation-based scenario of an envenomated child who requires treatment with antivenom. Optional additions to this scenario are described and include antivenom reaction, health equity considerations, and virtual facilitation.

In this technical report, we describe how to use TeleSimBox to run a remotely facilitated simulation to connect the facilitator with learners at a distant site. This method was developed to comply with safety measures imposed during the coronavirus disease-19 (COVID-19) pandemic to reduce the risk of viral exposure and transmission. Here, we present one example where a telesimulation naive facilitator was trained as an in-person facilitator to enable the in-situ medical student and resident learners to participate in a pediatric emergency simulation exercise remotely guided by an off-site content expert. The case of neonatal shock was run five times during a half-day emergency department (ED) educational program with one to four participants per session. 14/15 (93%) participants completed evaluations and felt that the simulation met the case learning objectives and that connecting with the remote facilitator was useful for their learning. Feedback from the one newly trained in-person facilitator was that the tool was easy to learn how to use quickly, and the process of connecting with a remote expert was worthwhile for learners. To grab this web-based toolkit off the proverbial shelf and successfully run a telesimulation session from start to finish took approximately one hour; 20 minutes were spent in preparation the day prior and 40 minutes to set up and run the simulations the day of. We believe that this is a low-cost, efficient, and perceived to be an effective method to connect remotely located content experts and learners to engage in a simulation-based education activity when access to in-person resources and personnel is limited.

Physical abuse is a significant cause of infant morbidity and mortality. Early detection in the emergency department (ED) is crucial.We describe the impact of a clinical pathway focused on early involvement of the child protection team (CPT) and social work (SW) team for infants presenting to a pediatric emergency department with an injury concerning for abuse.The pathway lists 10 injuries associated with abuse in infants and directs consultation of the CPT and SW. It was implemented at a single site on April 1, 2014. Seasonally matched data were collected 12 months before and after implementation on all children12 months of age with a qualifying injury. Demographics, CPT and SW consults, referral to Child Protective Services, diagnostic studies, and ultimate determination of abuse by the CPT were collected.Implementation of the pathway was associated with an increase in consultation of the CPT from 17% to 47% (p 0.001) and SW from 33% to 52% (p 0.001). CPT and SW consultations were obtained more frequently for those on public compared to private insurance prior to implementation but not after (CPT: odds ratio [OR] 4.32; p = 0.046; 95% confidence interval [CI] 1.03-18.15; SW: OR 3.23, p = 0.034; 95% CI 1.09-9.74). Diagnostic testing increased in the post-pathway period. There was no difference in the detection of abusive injury or number of missed cases.These findings suggest that this clinical pathway was successful in increasing involvement of the CPT and SW teams and reducing socioeconomic disparity in the evaluation of infants with injuries concerning for abuse.

BACKGROUND: Pediatric airway management is a challenging process at community emergency departments (CEDs) due to lower pediatric volume, a lack of pediatric expertise among staff, and a lack of pediatric-specific equipment and resources. This has contributed to increased mortality in pediatric patients presenting to CEDs in comparison to pediatric academic medical centers (AMCs). We hypothesized that a collaborative program between CEDs and the state AMC would improve the quality of pediatric airway management provided by CEDs in simulated settings and the CEDs9 pediatric emergency readiness scores. METHODS: This prospective, pre- and post-intervention study utilized in situ simulation and was conducted in 10 CEDs in the state of Indiana. A team from the pediatric AMC led a multi-faceted improvement program, which included post-simulation debriefing, addressing pediatric airway management issues, targeted assessment reports, access to pediatric resources, and ongoing communication with the AMC. The primary outcome of the study was improvement of simulated pediatric airway management in the CEDs. The secondary outcome was improvement of the CEDs9 pediatric emergency readiness scores score. RESULTS: A total of 35 multidisciplinary teams participated in pre-intervention sessions, and 40 teams participated in post-intervention sessions. Overall adherence to a critical action checklist improved from 52% at the pre-intervention visits to 71% post-intervention (P = .003). There were significant improvements in the use of appropriate endotracheal tube (ETT) size (from 67% to 100%, P = .02), cuffed ETT (from 8% to 71%, P CONCLUSIONS: A collaborative improvement program between a pediatric AMC and CEDs improved the CEDs9 simulated pediatric emergency airway management. This model can be utilized to improve management of other pediatric critical conditions in these CEDs.

Objectives The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. Methods This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. Results A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. Conclusions This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

Oral injuries in young children may indicate physical abuse. The prevalence of oral injuries in young children presenting to the emergency department is unknown. These data would assist providers in making decisions about the need for further abuse evaluation.To determine the prevalence of oral injuries, associated chief complaints and characteristics, and frequency of abuse evaluations in children younger than 24 months presenting to a pediatric emergency department (PED).Twelve pediatric emergency medicine physicians consecutively enrolled children younger than 24 months in a tertiary care PED.We performed a prospective observational study. Enrolled patients underwent a complete oral examination. Providers recorded patient demographics, type of chief complaint, oral injury details, developmental ability, and the presence of an abuse evaluation.Oral injuries occurred in 36/1303 (2.8%, 95% CI 1.9-3.8%) and were more common in patients with traumatic (26/200, 13%) versus medical chief complaints (10/1,103, 0.9%) (p .001). Of patients with oral injuries (36), 78% were mobile and 72% had traumatic chief complaints. Nine (25%) children with oral injuries were evaluated for abuse. Oral injuries in children 0-11 months old were more likely to be evaluated for abuse than children 12-24 months old (70.0% vs. 7.7%, p .001).The prevalence of oral injuries in children24 months old presenting to a PED was low. Most occurred in mobile children and in children with traumatic chief complaints. Younger, non-mobile children with oral injuries had a higher likelihood of having an abuse evaluation.

OBJECTIVES: The current pandemic has pushed medical educators to rethink traditional learning constructs as residents are experiencing fewer patient contacts in the pediatric emergency department (PED). Especially for those bound for a career in pediatric emergency medicine (PEM), we designed a curriculum to proactively address this emerging learning gap, incorporating a wellness "check-in" at the beginning of each session. The objective of this report is to share the themes of this wellness check-ins with those engaged in pediatric emergency medicine education and mentorship. Additionally, we share our curricular approach as we plan to continue PEM Pals after the pandemic restrictions are lifted. METHODS: "PEM Pals" is a twice-weekly video conference meeting made up of pediatric residents with an expressed interest in PEM and those residents currently on rotation in the pediatric emergency department. Following a flipped classroom model, participants complete a presession learning activity and then core PEM topics are covered through literature review, case discussions, and telesimulations. Each meeting begins with a wellness "check-in." Themes generated from these check-ins were member checked by our core learning contingent. RESULTS: Nine residents make up our core learning contingent and we have had 11 "PEM Pals" sessions since March 2020. Three themes emerged from the wellness check-ins. The first was each postgraduate year's unique concern over professional transitions. The second was a pervasive sense of guilt. And the third was a grave concern about their ability to support and be supported from their personal communities. CONCLUSIONS: The goal of our curriculum was to supplement an anticipated knowledge gap. Through use of a wellness "check-in," we elicited important themes for PEM educational leaders to consider as they mentor pediatric residents toward a career in PEM during the pandemic.

Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.

Background The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. Methods This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. Results We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. Conclusions We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

Introduction The opioid epidemic impacts all ages, yet few published medical education curricula exist to train physicians on how to care for opioid use disorder (OUD) in adolescents, a developmental stage where confidentiality protection is appropriate and contributes to quality health care. We developed a simulation-based educational intervention to increase addiction medicine and addiction psychiatry trainees’ confidence in managing adolescents with OUD. Methods Trainees completed a confidence survey and viewed an educational video covering state-specific confidentiality laws pertinent to treating adolescents with OUD. One week later, trainees participated in a simulated encounter where they described the scope of confidentiality to a trained actor, used the Clinical Opiate Withdrawal Scale to assess symptoms of opioid withdrawal, and explained adolescent-specific OUD medication treatment options. Immediately afterward, trainees completed a self-reflection and satisfaction survey and participated in a debriefing session with a faculty member where they identified learning goals. One month later, they completed the confidence survey to quantify changes in confidence. Results Thirty-five fellows (21 male, 14 female) completed the simulation-based educational intervention between 2016 and 2019. When asked to answer yes or no, 96% of participants described the exercise as effective and 100% (n = 26) would recommend it to peers. In addition, learners identified future learning goals, including researching specific topics and seeking out additional opportunities to evaluate adolescents with OUD. Discussion Based on our participants’ report, this simulation-based educational intervention is an effective teaching method for increasing trainee confidence in managing adolescents with OUD.

OBJECTIVE To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN A retrospective cohort study (January 2015 to December 2018) of all pediatric patients

Objective To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs. Study design This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: postsimulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network’s Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders. Results A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention. Conclusion A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.

Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [ Pediatr Ann . 2021;50(1):e19–e24.]

Supplemental Digital Content is available in the text., Introduction: The primary aim of this quality improvement initiative was to decrease the use of computerized tomography (CT) in the evaluation of pediatric appendicitis in a community general emergency department (GED) system by 50% (from 32% to 16%) in 1 year. Methods: Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and “over-transfer” rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. Results: The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children’s hospital rate of 23.5%, and an “over-transfer” rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. Conclusions: Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.

Telesimulation utilizes communications technology, such as video conferencing platforms, to provide simulation-based medical education when participants and facilitators are geographically separated. Learners interact with each other, embedded participants, and a simulated patient and/or vital sign display on the computer screen. Facilitators observe the learners in real-time and provide immediate feedback during a remote debrief. Telesimulation obviates the need to have instructors, learners, and high fidelity patient simulators (HPS) in the same place, allowing simulation-based educational sessions to occur in institutions located remotely from simulation centers or when other barriers limit in-person education and/or training. For example, due to the novel coronavirus (COVID-19) pandemic, many medical education programs temporarily discontinued in-person simulations to adhere to physical distancing guidelines. The authors have reflected upon their experiences executing telesimulation sessions since the start of the pandemic and provide these 12 tips as practical suggestions on how to successfully implement telesimulations with medical trainees. These tips are intended to guide implementation and facilitation by staff and faculty trained in simulation.

This chapter discusses strategies to identify and engage healthcare subject matter experts (SME) and stakeholders in projects applying simulation. Developing positive and cohesive working relationships between healthcare subject matter experts, simulation experts and other stakeholders will optimize the success of system improvement work.

Objective We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States. Methods We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network. Results We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%). Conclusions This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017.As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability.Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P .001).Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one.

BACKGROUND: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. OBJECTIVES: Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. METHODS: A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. RESULTS: 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. CONCLUSION: BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Introduction Advanced airway management in pediatrics is a rare, high stakes skillset. Developing proficiency in these skills is paramount, albeit challenging. Providers require innovative approaches to address initial training and maintenance of procedural competency. To address this, we developed a multimodality curriculum. Methods Through an interactive problem-based learning session utilizing real intubation videos, hands-on skill stations, and two simulation-based scenarios, participants advanced through educational objectives towards the goal of improving perceived comfort, knowledge, skills, and attitudes in emergency pediatric advanced airway management. Content was developed by integrating varied learning modalities under the learn, see, practice, prove, do, maintain construct. Please note the specialized equipment needed for this curriculum included pediatric airway trainers and a video laryngoscope. Results We have conducted the curriculum in its entirety four times, reaching 131 interdisciplinary participants. Forty-nine physicians of varying training backgrounds and clinical working environments completed postparticipation evaluations. On a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), a significant improvement in perception of comfort with managing the emergent pediatric airway was noted (2.7 to 4.6, p < .0001). Further, 94% of participants reported they strongly agreed (71%) or agreed (23%) that each station added to their perceived knowledge, skills, and attitudes of pediatric airway management. Discussion After participating in our curriculum, participants self-reported improved comfort in managing the emergent pediatric airway. This curriculum provides educators with resources to navigate the paradigm of obtaining and maintaining competency of a rare but critical skillset.

INTRODUCTION: This cross-sectional study looked at the impact of the SARS-CoV-2/COVID-19 pandemic on pediatric emergency department (PED) attendances and admissions (as a proxy for severity of illness) in the United States and United Kingdom. METHODS: Data were extracted for children and adolescents, younger than 16 years, attending Royal Manchester Children's Hospital (RMCH, United Kingdom), and Yale New Haven Children's Hospital (YNHCH, United States). Attendances for weeks 1 to 20 of 2020 and 2019 were compared, and likelihood of admission was assessed via calculation of odds ratios, using week 13 (lockdown) as a cutoff. RESULTS: Attendance numbers for each PED decreased in 2020 compared with 2019 (RMCH, 29.2%; YNHCH, 24.8%). Odds of admission were significantly higher after lockdown than in 2019-RMCH (odds ratio, 1.26; 95% confidence interval, 1.08-1.46) and YNHCH (odds ratio, 1.60; 95% confidence interval, 1.31-1.98). CONCLUSIONS: Although the absolute numbers of children and adolescents attending the PED and being admitted decreased after lockdown, the acuity of illness of those attending appears to be higher.

With increasing use of open access platforms, simulation-based resources are being shared across geographical borders. There are benefits to designing resources with language and content which is understandable and applicable to learners in different countries. This report aims to assess the differences between scenarios from different groups and explore whether common terms can be used to make internationally relevant simulation resources in future. In collaboration between two groups producing Free Open Access Medical Education simulation resources in the UK and USA, we present observations of terms used in our simulation resources. The content within a series of simulation scenarios from both groups was reviewed, with notable differences in language collected. There are areas of overlap between the terms used in the UK and USA. Semantic, cultural and system differences were found which could prevent scenarios from being transferred between countries. The differences we describe highlight that language choice is important if simulation producers are intent on developing scenarios with international impact. There is work to be done to ensure that resources can be used internationally—embracing linguistics has the potential to aid this process, with the use of simplified language and feedback from local communities being key steps.

BACKGROUND The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections. AIM To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide. METHODS A cross-sectional multi-center national survey of PICU medical director(s) from children’s hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation. RESULTS We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children’s hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives. CONCLUSIONS A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.

Introduction Many emergency medicine (EM) physicians have limited training in the care of sexual assault patients. Simulation is an effective means to increase the confidence and knowledge of physicians in such high-stakes, low-frequency clinical scenarios as sexual assault. We sought to develop and implement a sexual assault simulation with a structured debriefing for EM residents and to determine its impact on resident learners’ attitudes and knowledge skills in the care of patients with sexual assault. Methods The simulation blended psychomotor skills (e.g., collecting forensic evidence), cognitive skills (e.g., ordering laboratory studies and medications), and communication skills (e.g., obtaining relevant patient history, responding to psychosocial concerns raised by team members and simulator). Our emergency department checklist was available as a cognitive aid for each step of the evidence collection process. A content expert answered questions in real time during the simulation and provided structured debriefing following the simulation. Trainees completed an anonymous survey within a week after the intervention and a follow-up survey within 8 months. Results Nineteen EM trainees participated. Presimulation, 39% reported never having received training in the medical care of a patient with sexual assault. The proportion of trainees agreeing or strongly agreeing with the statement “I am comfortable and confident managing a case of sexual assault” increased from 21% to 74% following the simulation (p < .05). Discussion This intervention was associated with EM trainees’ increased confidence with and knowledge of medical and forensic evaluations for an adolescent with sexual assault.

OBJECTIVE: To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN: A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS: Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P

IntroductionEmergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists.Methods and analysisOur proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period.Ethics and disseminationEthical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

OBJECTIVES Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age. METHODS A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis. RESULTS Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively. CONCLUSION Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).