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Point-of-care ultrasound (POCUS) is used to manage patients in real time. This study aimed to teach pediatric critical care team members to use POCUS for endotracheal tube (ETT) placement confirmation. A secondary aim was to assess the feasibility of a remote curriculum for this purpose.The Kern 6-step approach was used. The curriculum involved virtual didactics, asynchronous learning modules, and remote hands-on sessions using teleguidance with the Butterfly IQ+ probe, Butterfly Network, Inc, Guilford, CT. Participants learned direct and indirect methods of ETT placement confirmation and were directed to practice independently. Outcomes included attitudes and satisfaction, knowledge and skills acquisition and retention, and the use of POCUS on shift.Ten participants completed the curriculum. The average knobology and quiz scores improved by 29.3% and 20.8%, respectively. Improvement was sustained at re-evaluation. Seven of 10 participants performed independent scans. At the 3-month reassessment, most demonstrated mastery of thoracic scans. All required prompting for satisfactory tracheal scans. All felt positively toward POCUS and the remote curriculum.Pediatric critical care team members acquired and retained knowledge and skills for POCUS basics and ETT placement confirmation through a remote curriculum. Participants were satisfied with the course. Further studies are needed to reassess longer-term knowledge and skill retention and the effects on patient outcomes.

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.

Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings. We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking. Small groups (n = 121) and survey ranking (n = 54) were used with This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of

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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.

In 2017, the Health Resources and Services Administration's Maternal Child and Health Bureau's Emergency Medical Services for Children program implemented a performance measure for State Partnership grants to increase the percentage of EMS agencies within each state that have designated individuals who coordinate pediatric emergency care, also called a pediatric emergency care coordinator (PECC). The PECC Learning Collaborative (PECCLC) was established to identify best practices to achieve this goal. This study's objective is to report on the structure and outcomes of the PECCLC conducted among nine states.This study used quantitative and qualitative methods to evaluate outcomes from the PECCLC. Participating state representatives engaged in a 6-month collaborative that included monthly learning sessions with subject matter experts and support staff and concluded with a two-day in-person meeting. Outcomes included reporting the number of PECCs recruited, identifying barriers and enablers to PECC recruitment, characterizing best practices to support PECCs, and identifying barriers and enablers to enhance and sustain the PECC role. Outcomes were captured by self-report from participating state representatives and longitudinal qualitative interviews conducted with representative PECCs at 6 and 18 months after conclusion of the PECCLC.During the 6-month collaborative, states recruited 341 PECCs (92% of goal). Follow up at 5 months post-collaborative revealed an additional recruitment of 184 for a total of 525 PECCs (142% of the goal). Feedback from state representatives and PECCs revealed the following barriers: competition from other EMS responsibilities, budgetary constraints, lack of incentive for agencies to create the position, and lack of requirement for establishing the role. Enablers identified included having an EMS agency recognition program that includes the PECC role, train-the-trainer programs, and inclusion of the PECC role in agency licensure requirements. Longitudinal interviews with PECCs identified that the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support.Over the 6-month Learning Collaborative, nine states were successful in recruiting a substantial number of PECCs. Financial and time constraints were significant barriers to statewide PECC recruitment, yet these can be potentially addressed by EMS agency recognition programs.

Injured children initially treated at trauma centers with high emergency department (ED) pediatric readiness have improved survival. Centers with limited resources may not be able to address all pediatric readiness deficiencies and there currently is no evidence-based guidance for prioritizing different components of readiness. The objective of this study was to identify individual components of ED pediatric readiness associated with better-than-expected survival in US trauma centers to aid in the allocation of resources targeted at improving pediatric readiness.This cohort study of U.S. trauma centers used the National Trauma Data Bank (2012-2017) matched to the 2013 National Pediatric Readiness Project assessment. Adult and pediatric centers treating at least 50 injured children (age18 years) and recording at least one death during the 6-year study period were included. Using a standardized risk-adjustment model for trauma, we calculated the observed-to-expected (O/E) mortality ratio for each trauma center. We used bivariate analyses and multivariable linear regression to assess for associations between individual components of ED pediatric readiness and better-than-expected survival.Among 555 trauma centers, the O/E mortality ratios ranged from 0.07 to 4.17 (IQR 0.93, 1.14). Unadjusted analyses of 23 components of ED pediatric readiness showed that trauma centers with better-than-expected survival were more likely to have a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment (all p0.03). The multivariable analysis demonstrated that trauma centers with both a physician and a nurse pediatric emergency care coordinator had better-than-expected survival, but this association weakened after accounting for trauma center level. Child maltreatment policies were associated with lower-than-expected survival, particularly in Level III-V trauma centers.Specific components of ED pediatric readiness were associated with pediatric survival among US trauma centers.Care management, level III.

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.

SimBox simulations allow for high-frequency open-access health care education, overcoming cost and resource barriers. Prehospital paramedics and emergency medical technician (EMT) care for children infrequently. In this study, prehospital providers evaluated pediatric SimBox simulations.This was a cross-sectional study of EMS professionals participating in a series of simulations conducted in a larger project assessing improvement of the quality of pediatric care in the prehospital setting. Participants were teams of two, which comprised a paramedic/paramedic, paramedic/EMT, or 2 EMTs. The simulations used facilitator resources, debriefing prompts, video depictions of patients and vital signs, and a low-fidelity manikin. Pediatric emergency care coordinators, EMS training officers, and/or emergency physicians facilitated simulations of seizure, sepsis with respiratory failure, and child abuse, followed by debriefings. Participants completed an online survey after the simulation and rated it in 4 domains: prebriefing, scenario content, debriefing, and overall. Ratings were trifold: "strongly agree," "somewhat agree," or "do not agree." Data were analyzed by case type, participant type, location, participant reaction to simulation elements, and the debriefing. Net Promoter Scores were calculated to assess participant endorsement of SimBox.There were 121 participants: 103 (87%) were paramedics, and 18 (13%) were EMTs. Participant agreement of simulation benefit for clinical practice was high, for example, "I am more confident in my ability to prioritize care and interventions" (98.4% strongly or somewhat agree), and 99.2% of participants agreed the postsimulation debriefing with facilitators "provided opportunities to self-reflect on my performance during simulation." Overall, 97.5% strongly or somewhat agreed that the simulations "improved my comfort in pediatric acute care." Net Promoter Score showed 65.3% were promoters of and 24% were passive about SimBox.SimBox simulations are associated with improved self-efficacy of prehospital care providers for care of acutely ill or injured children. The majority promotes SimBox as a learning tool.

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.

Background The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills. Methods All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation. Results Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation. Conclusions Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.

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.

Objectives Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs. Methods Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items. Results A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs. Conclusions The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

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.