Arielle Levy

Evaluation of a New Strategy for Clean-Catch Urine in Infants.

BACKGROUND AND OBJECTIVES: A new noninvasive bladder stimulation technique has been described to obtain clean-catch urine (CCU) in infants aged <30 days. Objectives were (1) to determine proportion and predictive factors for successful CCU collections using a stimulation maneuver technique among infants <6 months and (2) to determine the proportion of bacterial contamination with this method. METHODS: A prospective cohort study was conducted in a tertiary pediatric emergency department among infants <6 months needing a urine sample. CCU samples were collected using a standardized stimulation technique. Invasive technique was performed after CCU for three specific conditions. Primary outcomes were proportions of successful CCU specimens and bacterial contamination. We determined associations between successful urine samples and 4 predictive factors (age, sex, low oral intake, and recent voiding). RESULTS: A total of 126 infants were included (64 boys, median age: 55 days). The CCU procedure was effective in 62 infants (49%; median time: 45 seconds). Infants 0 to 29 days; 30 to 59 days, and 60 to 89 days had more successful procedures, compared with infants >89 days (odds ratios [95% confidence interval (CI)]: 4.3 [1.4 to 13.4]; 3.2 [1.2 to 8.4]; and 4.44 [1.5 to 13.3], respectively). The contamination proportion was 16% (95% CI: 8% to 27%) in the CCU group. This proportion was not statistically different compared with the invasive method group (6%, 95% CI: 3% to 15%). CONCLUSIONS: The CCU procedure is a quick and effective noninvasive method in children aged <90 days. Contamination proportions were similar to those reported in the literature for urethral catheterization. Circumstances for which the CCU procedure could be performed are proposed.

Lack of efficacy of phenytoin in children presenting with febrile status epilepticus.

BACKGROUND Fever is the most common precipitant of status epilepticus in children. Animal models suggest that only γ-aminobutyric acidic drugs are effective in the treatment of febrile seizures, but there is limited clinical evidence to support this. OBJECTIVE The aim of this study was to determine the efficacy of phenytoin, a sodium channel blocker, in the treatment of febrile status epilepticus in children. METHODS This study is a retrospective chart review of 56 children (62 episodes) who presented to our emergency department with febrile status epilepticus and received phenytoin. The clinical parameters were evaluated by reviewing the charts. The efficacy of phenytoin was classified into 3 categories: positive, negative, and nonevaluable response. RESULTS The primary outcome was to evaluate the efficacy rate of phenytoin; there were 9 (14.5%) of 62 episodes with a positive response, 25 (40.3%) with a negative response, and 28 (45.2%) with a nonevaluable response because phenytoin was given simultaneously with a γ-aminobutyric acidic (GABAergic) drug (P < .001). The secondary outcome was to measure the mean seizure duration for each treatment category, which were 52.8, 109.9, and 52.6 minutes, respectively (P < .01). CONCLUSION Phenytoin is rarely effective in controlling febrile status epilepticus. Children exposed to phenytoin have more prolonged febrile seizures, increasing the risk of brain injury.

Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial

Precalculated medication doses reduce harmful prescribing errors in emergency situations and should be available in all settings where children could present in critical conditions. OBJECTIVE: To evaluate whether a clinical aid providing precalculated medication doses decreases prescribing errors among residents during pediatric simulated cardiopulmonary arrest and anaphylaxis. METHODS: A crossover randomized trial was conducted in a tertiary care hospital simulation center with residents rotating in the pediatric emergency department. The intervention was a reference book providing weight-based precalculated doses. The control group used a card providing milligram-per-kilogram doses. The primary outcome was the presence of a prescribing error, defined as a dose varying by ≥20% from the recommended dose or by incorrect route. Residents were involved in 2 sets of paired scenarios and were their own control group. Primary analysis was the difference in mean prescribing error proportions between both groups. RESULTS: Forty residents prescribed 1507 medications or defibrillations during 160 scenarios. The numbers of prescribing errors per 100 bolus medications or defibrillations were 5.1 (39 out of 762) and 7.5 (56 out of 745) for the intervention and control, respectively, a difference of 2.4 (95% confidence interval [CI], −0.1 to 5.0). However, the intervention was highly associated with lower risk of 10-fold error for bolus medications (odds ratio 0.27; 95% CI, 0.10 to 0.70). For medications administered by infusion, prescribing errors occurred in 3 out of 76 (4%) scenarios in the intervention group and 13 out of 76 (22.4%) in the control group, a difference of 13% (95% CI, 3 to 23). CONCLUSIONS: A clinical aid providing precalculated medication doses was not associated with a decrease in overall prescribing error rates but was highly associated with a lower risk of 10-fold error for bolus medications and for medications administered by continuous infusion.

External validation of scoring instruments for evaluating pediatric resuscitation.

Introduction Although many methods have been proposed to assess clinical performance during resuscitation, robust and generalizable metrics are still lacking. Further research is necessary to develop validated clinical performance assessment tools and show an improvement in outcomes after training. We aimed to establish evidence for validity of a previously published scoring instrument—the Clinical Performance Tool (CPT)—designed to evaluate clinical performance during simulated pediatric resuscitations. Methods This was a prospective experimental trial performed in the simulation laboratory of a pediatric tertiary care facility, with a pretest/posttest design that assessed residents before and after pediatric advanced life support (PALS) certification. Thirteen postgraduate year 1 (PGY1) and 11 PGY3 pediatric residents completed 5 simulated pediatric resuscitation scenarios each during 2 consecutive sessions; between the 2 sessions, they completed a full PALS certification course. All sessions were video recorded. Sessions were scored by raters using the CPT; total scores were expressed as a percentage of maximum points possible for each scenario. Validity evidence was established and interpreted according to Messick’s framework. Evidence regarding relations to other variables was assessed by calculating differences in scores between pre-PALS and post-PALS certification and PGY1 and PGY3 using a repeated-measures analysis of variance test. Internal structure evidence was established by assessing interrater reliability using intraclass correlation coefficients (ICCs) for each scenario, a G-study, and a variance component analysis of individual measurement facets (scenarios, raters, and occasions) and associated interactions. Results Overall scores for the entire study cohort improved by 10% after PALS training. Scores improved by 9.9% (95% confidence interval [CI], 4.5–15.4) for the pulseless nonshockable arrest (ICC, 0.85; 95% CI, 0.74–0.92), 14.6% (95% CI, 6.7–22.4) for the pulseless shockable arrest (ICC, 0.98; 95% CI, 0.96–0.99), 4.1% (95% CI, −4.5 to 12.8) for the dysrhythmias (ICC, 0.92; 95% CI, 0.87–0.96), 18.4% (95% CI, 9.7–27.1) for the respiratory scenario (ICC, 0.97; 95% CI, 0.95–0.98), and 5.3% (95% CI, −1.4 to 2.0) for the shock scenarios (ICC, 0.94; 95% CI, 0.90–0.97). There were no differences between PGY1 and PGY3 scores before or after the PALS course. Reliability of the instrument was acceptable as demonstrated by a mean ICC of 0.95 (95% CI, 0.94–0.96). The G-study coefficient was 0.94. Most variance could be attributed to the subject (57%). Interactions between subject and scenario and subject and occasion were 9.9% and 1.4%, respectively, and variance attributable to rater was minimal (0%). Conclusions Pediatric residents improved scores on CPT after completion of a PALS course. Clinical Performance Tool scores are sensitive to the increase in skills and knowledge resulting from such a course but not to learners’ levels. Validity evidence from scores for the CPT confirms implementation in new contexts and partially supports internal structure. More evidence is required to further support internal structure and especially to support relations with other variables and consequence evidence. Additional modifications should be made to the CPT before considering its use for high-stakes certification such as PALS.

Training: Simulating Pediatric Airway

Training in the management of pediatric airway cases has been limited by the number of cases and by the involved risks to the child. Simulation is an alternative and accessible means to practice that complex psychomotor task in a safe and reproducible environment. A high-fidelity baby mannequin provides an acceptable airway anatomic resemblance combined with measurable respiratory and cardiovascular parameters, allowing practice to be interactive and challenging. The availability of simulation laboratories within hospitals and the development of pathology-inspired accessories for the mannequins will determine the rate of adherence of ENT departments to this evolving field of simulation-based education.

Board 373 - Research Abstract High-Fidelity Simulation Results in Improvement of Clinicians Performance in the Management of Massive Hemorrhage Cases (Submission #64)

Introduction/Background A massive haemorrhage can be a rare but serious complication of paediatric trauma and obstetrical cases. In order to optimize the management of massive haemorrhages, a protocol was implemented at our centre. However, recent audits showed that necessary improvements were to be made to many aspects of its application. Our objective was to evaluate the application of a massive hemorrhage protocol and the ability to work in interdisciplinary teams using simulation and targeted training. We also aimed to evaluate confidence levels of different team members to apply the protocol and to hold their role in an interdisciplinary team during a crisis situation. Methods Prospective observational study held at the simulation lab and at the blood bank of a tertiary mother-child health care facility in 2012. Participants were nurses, respiratory therapists, orderlies, anesthetists, obstetricians, pediatric emergency physicians, intensivists and hematologists, as well as blood bank technologists. Pediatric emergency/intensive care and obstetrical/anesthesia teams were submitted to high-fidelity (HF) simulated pediatric trauma and post-partum massive hemorrhage scenarios respectively (SimbabyTM (Laerdal) and NoelleTM (Gaumard)). Blood bank technologists were videotaped and telephone conversations between them and participants at the simulation lab were recorded for review. If hematologists were consulted, they were called back by the blood bank chief technologist and asked to answer questions relevant to the application of the massive hemorrhage protocol (MHP). Each participant was asked to hold their usual role in an interdisciplinary team. Scenarios were developed, programmed and run by experts in each field. Targeted training consisted of a debriefing session and a presentation reviewing the MHP and teamwork skills. Documents on MHP, as well as a key article on crisis resource management were distributed during the first session in order to prepare for the post session two weeks later. Confidence questionnaires were filled out during both sessions. All sessions were videotaped and four blinded independent trained raters assessed the performances. Raters were blinded to the pre/post phase and were not involved in the study. For the application of the massive hemorrhage protocol performances, raters used a checklist derived from the original protocol by experts in the field. For the ability to work in teams, raters used the Mayo High Performance Teamwork Scale. Blood bank technologists were evaluated using a checklist derived by transfusion experts rating necessary steps for preparing and delivering blood products in cases of massive haemorrhages. Scores on performances of the application of the protocol, as well as teamwork performances were recorded. Means and standard deviations of scores for performances were calculated for each scenario. Pre and post training scores were compared using an ANOVA test to assess differences in means. Descriptive statistics of items on the confidence questionnaire were calculated prior to and following training. To assess differences in confidence levels, a Mann Whitney test was used. An alpha of 0.05 was set for all statistics. Results A total of 62 healthcare professionals involved in 8 interdisciplinary teams (4 obstetrics/anaesthesia and 4 paediatric emergency/intensive care) as well as 8 blood bank technologists and 8 haematologists participated in the study. Following training, scores for the application of the protocol improved by 24% (95% CI 10-39). Scores for the ability to work in teams improved by 17% (95% CI 6-28). Confidence levels in the ability to apply the protocol and work in teams improved by 13% (95% CI 11-16). Notable were confidence improvements in leadership and communication skills as well as role and task assignment. Conclusion Targeted training involving HF simulated scenarios and protocol review improved participant ability to apply the massive haemorrhage protocol and to work in interdisciplinary teams. Confidence levels improved among participants from all disciplines. Disclosures None.

Transitioning from medical school to residency: Evaluation of an innovative immersion rotation for PGY-1 paediatric residents

Transition from medical school to residency is stressful due to new responsibilities in patient care. Objective To evaluate a new immersion curriculum on the transition from medical school to paediatric residency and its implications for future use in paediatric education. Methods In July 2013, a month-rotation offering one-third of time for clinical rounds and two-thirds of time for formal courses was conducted for postgraduate year 1 residents beginning paediatric residency training. Surveys were administered to residents before and after this rotation about their self-confidence in several paediatrics topics and abilities. Results Eleven junior residents were enrolled (100% participation rate). Among this cohort, pre- and postintervention confidence surveys showed differences for neonatalogy (P<0.001), respiratory distress (P=0.01) and seizure management skills (P<0.001). Among abilities surveyed, significant differences were noted for medical emergencies (P<0.001) and drug prescriptions (P<0.002). The healthy childcare item was the only topic with decreased self-confidence levels. Overall, 45.5% of participants felt confident and ready to begin clinical rotations in the paediatric program following completion of the rotation. Conclusion First year paediatric residents who participated in this new curriculum felt their confidence was enhanced in several areas of paediatrics. These findings supported our program committee members in their decision to pursue this rotation since 2013, and may be generalizable to other programs and institutions.

Mannequin-Based Simulators and Task Trainers

Mannequin-based simulators offer specialized functions with compact control systems and minimal physical space requirements. They allow operators to maximize fidelity and learner experiences and optimize the simulator’s use as a research and assessment tool. Mannequin-based simulators are available in autonomous and manual forms, and key differences exist between pediatric and adult models. Various part task trainers can be selected, in addition to whole body simulators, and they allow for a wide range of procedural skills to be performed. Effective programming is key and helps optimize the learning experience.

Board 372 - Research Abstract The Other End: Evaluation of Blood Bank Technologists and Hematologists During a Massive Hemorrhage High-Fidelity Simulation Project (Submission #71)

Introduction/Background Massive hemorrhages are infrequent but life threatening complications of pediatric trauma and obstetrical cases. Expertise and effective communication is key among all team members actively involved in managing such events. Collaboration with blood bank technologists and hematologists responsible in assisting the team with prompt preparation and delivery of blood products further contributes to optimal patient care. We aimed to evaluate communication skills and expertise when preparing and delivering blood products in cases of massive haemorrhages using in-situ simulation and telemedicine. Methods Prospective observational study held at the blood bank and simulation lab of a tertiary mother-child health care facility in 2012. Participants were nurses, respiratory technicians, anesthetists, obstetricians, emergency physicians, intensivists, hematologists and blood bank technologists. Pediatric emergency/intensive care and obstetrical/anesthesia teams were submitted to high fidelity (HF) simulated pediatric trauma and post-partum massive hemorrhage scenarios respectively (SimbabyTM (Laerdal) and NoelleTM (Gaumard)) in the simulation lab. Concomitantly, blood bank technologists were videotaped and telephone conversations between participants at the simulation lab and blood bank technologists were recorded for review. If hematologists were consulted, they were called back by the blood bank chief technologist and were asked to answer questions relevant to the application of the massive hemorrhage protocol (MHP). Prior to the first simulation, blood bank technologists were asked to read the MHP and were individually met to answer questions. The MHP was explained to the hematologists during a formal group presentation and they had access to it at any time during the course of the study. All participants were observed initially and during the post session, two weeks later. A blinded independent trained rater reviewed all sessions and assessed performances. Blood bank technologists were evaluated using a checklist derived by transfusion experts rating expertise and key communication skills necessary when preparing and delivering blood products to teams involved in massive haemorrhages. Haematologists were evaluated using a questionnaire developed by transfusion security experts exploring their ability to assist and communicate with blood bank technologists and clinicians when dealing with the choice of blood products or compatibility issues. Means and standard deviations of scores on checklists and questionnaires were calculated for all observations. Results A total of 8 blood bank technologists, 8 haematologists and 62 healthcare professionals involved in 8 interdisciplinary teams (4 obstetrics/anaesthesia and 4 paediatric emergency/intensive care) participated in the study. Blood bank technologists scored on average 78% (range 61%-92%) and 76% (range 62 to 100%) in expertise and communication skills checklists during trauma and post-partum simulations, respectively. Haematologists rightly refused blood specimens to determine blood type in 57% (4/7) of the cases (discrepant ABO/Rh blood group with previous ABO group Results). Their ability to choose blood products or to substitute them was observed in 71% (5/7) of participants. When challenged by the fact that an incompatible blood product was delivered to the bleeding patient, only 37.5% (3/8) asked for phenotype analysis of products already transfused and those being prepared and no one advised the team caring for the patient of this fact and of the possibility of a haemolytic transfusion reaction. Conclusion Blood bank technologists were considered to be relatively well prepared and possess the necessary expertise and communication skills to prepare and deliver blood products to obstetrical and paediatric trauma teams dealing with massive haemorrhages. For haematologists, knowledge gaps were identified and additional training will be mandatory to ensure proficiency when assisting teams dealing with such emergencies. Using in-situ simulation at the blood bank and telemedicine for haematologists, in addition to HF interdisciplinary team simulations occurring in a simulation lab, can further contribute to improving performances of all professionals actively involved in a massive haemorrhage crisis situation. Disclosures None.

Board 424 - Research Abstract Validation of a Tool for the Assessment of Trainees During Simulated Pediatric Resuscitation (Submission #967)

Introduction/Background Dealing with a patient in an emergency situation, such as cardiac arrest, is among the most challenging scenarios that a physician may face in their career. To better prepare trainees for such events, a growing number of residency programs are incorporating high-fidelity simulation into their training.1 As part such a curriculum, it is crucial to have a tool that can objectively assess performance of trainees during simulated resuscitations. Many tools have been proposed to measure clinical skills, but recently Grant2 developed a tool that assesses not only clinical performance but also leadership skills during simulated pediatric resuscitations. We aimed to validate Grant’s tool and assess inter-rater reliability of the instrument when used by providers not involved in the tool’s development. Methods This study took place in the simulation lab of a tertiary care pediatric center. In the setting of a previous study,3 a total of 13 first-year and 11 third-year residents were videotaped during simulated pediatric resuscitation scenarios. Each resident led five scenarios before and after their Pediatric Advanced Life Support (PALS) course. The pre and post-PALS scenarios were paired, such that each resident acted as team leader in a pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory and shock scenario. Five subspecialists in the fields of pediatric emergency medicine and intensive care from North America and Europe were trained to evaluate the residents’ performance using Grant’s assessment tool. All raters were blinded to the pre and post-PALS phases of the scenarios. Inter-rater reliability was assessed by having two expert raters independently evaluate the residents performance. In the absence of a gold standard scoring tool, we used construct validity to validate the tool. Knowing that the PALS course has been shown to increase immediate short-term knowledge of healthcare professionals,4 it was determined that, for the tool to be valid, participants should improve their score after participating in the PALS course. Pre and post-PALS scores were compared using a paired sample Student T-test. Inter-rater reliability was measured for the five scenarios using intra-class correlation coefficient (ICC). Results Following the PALS course, the residents scores improved by 11% (95%CI 6.1-16) for the pulseless non-shockable arrest, 17% (95%CI 11-24) for the pulseless shockable arrest, 6% (95%CI 0.1-12) for the dysrhythmias, 12% (95%CI 4.3-21) for the respiratory scenario, 14% (95%CI 7.3-21) for the shock scenarios. Inter-rater reliability was excellent as demonstrated by an overall intra-class correlation coefficient of 0.91 (95%CI 0.88-0.93). Conclusion Grant’s scoring instrument demonstrated construct validity and excellent reliability as a measure of clinical performance for simulated pediatric resuscitations. Moreover, we were able to show that it is a generalizable tool, as it was valid for all of our five simulated scenarios. Further research should be done to assess whether this tool is reliable when used to assess trainees in real-time rather than video-based assessments. References 1. Okuda Y, Bond W, Bonfante G, McLaughlin S, Spillane L, Wang E, Vozenilek J, Gordon JA: National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008; 15(11):1113-6. 2. Grant EC, Grant VJ, Bhanji F, Duff JP, Cheng A, Lockyer JM: The development and assessment of an evaluation tool for pediatric resident competence in leading simulated pediatric resuscitations. Resuscitation 2012; 83(7):887-93. 3. Levy A, Donoghue A, Jamoulle O, Gravel J, Bailey B, Thompson N: External validation of scoring instruments to evaluate paediatric resuscitations. Pediatr Child Health 2012; 17 (suppl A): 20-21. 4. Waisman Y, Amir L, Mimouni M: Does the pediatric advanced life support course improve knowledge of pediatric resuscitation? Pediatr Emerg Care 2002. 18(3):168-70. Disclosures None.