Beth L. Emerson

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy.

Background: GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). Purposes: This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. Methods: Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. Results: Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. Conclusions: A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

Effects of alcohol-based hand hygiene solutions on breath alcohol detection in the emergency department

This study aimed to investigate the effects of alcohol-based hand hygiene solution (ABHS) use by care providers on point-of-care alcohol breath analyzer interpretation under different clinically relevant conditions. Among each test condition (foam vehicle with immediate testing, gel vehicle with immediate testing, allowing hands to dry after the use of ABHS, and donning gloves after the use of ABHS), alcohol was detected in breath at 1 minute after use of ABHS. Because the use of ABHS by individuals administering breath alcohol detection may result in false-positive detection of alcohol, staff using these devices should consider traditional hand hygiene with soap and water.

Postpartum Depression Screening in the Pediatric Emergency Department

Purpose This study aimed to determine the prevalence of and risk factors for postpartum depression (PPD) in mothers of young infants presenting to the pediatric emergency department (PED). Methods This was a prospective, observational study to evaluate the prevalence of PPD in a sample of mothers of young infants presenting to the PED of an urban, tertiary care children’s hospital. A convenience sample of mothers with infants younger than 4 months who presented to our urban, tertiary care PED was surveyed in English or Spanish using the Edinburgh Postpartum Depression Scale (EPDS). Demographic information was collected. Members of the study team evaluated and counseled those mothers who screened positive on the EPDS (score ≥ 10). During the PED visit, social work consultation and mental health resources were also offered. Resource use and additional mental health needs were assessed, with a follow-up telephone call 4 weeks after the initial ED presentation. Performance characteristics of a brief, 3-question anxiety subset were compared using a positive EPDS as the reference standard. All study participants were given information about community resources for new mothers. Data were analyzed using t test or &KHgr;2 (with Yates correction as necessary). Results A convenience sample of 200 mothers was enrolled; 31 (16%) of these mothers had an EPDS score of 10 or greater. Mothers had a mean age of 27 years (range, 15–41); 45% were first-time mothers; 40% got pediatric care in a state-funded clinic; and 10% were Spanish speaking. There were no statistically significant differences in baseline demographic characteristics of mothers with and without PPD. Mothers who were depressed were more likely to report that they either strongly agreed or agreed with the statement “I feel that my child is always fussy” (P = 0.004). The anxiety subscale produced a sensitivity of 0.87 (95% confidence interval [CI], 0.69–0.96), a specificity of 0.70 (95% CI, 0.63–0.77), and a negative predictive value of 0.97 (95% CI, 0.91–0.99). The majority of participants (92%) reached at follow-up reported improvement in their mood. Fifty percent reported discussing their mood with someone else, although only 33% of these women did so with a medical provider. Conclusions Postpartum depression affects a significant number of mothers of young infants who present to the PED for medical care. There are no clear demographic identifiers of these at-risk mothers, making universal screening an advisable approach. Capture of at-risk mothers during PED visits may accelerate connection with mental health resources. Anxiety seems to be a significant contributor. Mothers with PPD often characterize their infants to have a “fussy” temperament. The most appropriate referral for these women in this setting merits further investigation.

An Initiative to Reduce Routine Viral Diagnostic Testing in Pediatric Patients Admitted with Bronchiolitis

BACKGROUND Bronchiolitis is a viral lower respiratory tract infection that causes significant morbidity and mortality in the pediatric population. Viral diagnostic testing (VDT) has been used to identify specific viral pathogens. However, current guidelines suggest that routine use of this testing is not advisable. For children admitted to a childrens hospital from the pediatric emergency department (PED), the rate of VDT was 63%, which was higher than the national rate. A quality improvement project was conducted to reduce the use of routine VDT. METHODS Key drivers of VDT were identified, and interventions, which included staff education about the cost and use of VDT and dissemination of a simplified cohorting policy aimed to eliminate VDT without medical necessity, were implemented through the PED and inpatient unit settings. RESULTS Between January 2017 and April 2017, VDT use in all non-ICU patients admitted from the PED with bronchiolitis decreased from 63% to 12%. In the same time period, patients with VDT sent from the PED fell from 53% to 14%. A reduction in VDT for patients admitted with asthma exacerbation was also observed-from 24% to 0%-demonstrating early spread of these effects. Cost savings of approximately

A taxonomy and cultural analysis of intra-hospital patient transfers

8,584 per year in direct supply costs alone was documented. CONCLUSION Using simple, low-cost interventions, including education and guideline refinement, the rate of VDT use for bronchiolitis was significantly reduced. Further directions for this project include the reduction of routine testing for patients with bronchiolitis who are admitted to the ICU or discharged for outpatient care.

An Initiative to Decrease Time to Antibiotics for Patients With Fever and Neutropenia

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units. We conducted observations of staff (n = 16) working in four hospital departments and interviewed staff (n = 29) involved in transfers to general medicine floors from either the Emergency Department or the Medical Intensive Care Unit between February and September 2015. The collected data allowed us to understand transfers in the context of several hospital cultural microsystems. Decisions were made through the lens of the specific unit identity to which staff felt they belonged; staff actively strategized to manage workload; and empty beds were treated as a scarce commodity. Staff concepts informed the development of a taxonomy of intra-hospital transfers that includes five categories of activity: disposition, or determining the right floor and bed for the patient; notification to sending and receiving staff of patient assignment, departure and arrival; preparation to send and receive the patient; communication between sending and receiving units; and coordination to ensure that transfer components occur in a timely and seamless manner. This taxonomy widens the study of intra-hospital patient transfers from a communication activity to a complex cultural phenomenon with several categories of activity and views them as part of multidimensional hospital culture, as constructed and understood by staff.

Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service

The objective was to decrease the time to antibiotic administration for patients arriving in the pediatric emergency department with fever and neutropenia. A multidisciplinary team was assembled and engaged in process analysis through interviews and data review. These findings were used to develop key drivers, and Pareto charts were utilized to prioritize interventions. Interventions were tested and implemented using rapid Plan-Do-Study-Act cycles. Progress was monitored using process control charts. Interventions included leveraging a secure text-based messaging platform, creating a new antibiotic pathway, and educating staff and family. Between September 2016 and September 2017, the average time to antibiotics was decreased from 116 to 55 minutes in this population. This also was associated with a decrease in variation (individual moving range mean decreased from 43 minutes to 18 minutes). Careful process analysis, coupled with the work of a multidisciplinary team, produced significant improvements in efficiency of care for these vulnerable patients.

Shoulder Dystocia and Neonatal Resuscitation: An Integrated Obstetrics and Neonatology Simulation Case for Medical Students

Objective: Overcrowding in the emergency department (ED) has been associated with patient harm, yet little is known about the association between ED boarding and adverse hospitalization outcomes. We sought to examine the association between ED boarding and three common adverse hospitalization outcomes: rapid response team activation (RRT), escalation in care, and mortality. Method: We conducted an observational analysis of consecutive patient encounters admitted from the ED to the general medical service between February 2013 and June 2015. This study was conducted in an urban, academic hospital with an annual adult ED census over 90,000. We defined boarding as patients with greater than 4 h from ED bed order to ED departure to hospital ward. The primary outcome was a composite of adverse outcomes in the first 24 h of admission, including RRT activation, care escalation to intensive care, or in‐hospital mortality. Results: A total of 31,426 patient encounters were included of which 3978 (12.7%) boarded in the ED for 4 h or more. Adverse outcomes occurred in 1.92% of all encounters. Comparing boarded vs. non‐boarded patients, 41 (1.03%) vs. 244 (0.90%) patients experienced a RRT activation, 53 (1.33%) vs. 387 (1.42%) experienced a care escalation, and 1 (0.03%) vs.12 (0.04%) experienced unanticipated in‐hospital death, within 24 h of ED admission. In unadjusted analysis, there was no difference in the composite outcome between boarding and non‐boarding patients (1.91% vs. 1.91%, p = 0.994). Regression analysis adjusted for patient demographics, acuity, and comorbidities also showed no association between boarding and the primary outcome. A sensitivity analysis showed an association between ED boarding and the composite outcome inclusive of the entire inpatient hospital stay (5.8% vs. 4.7%, p = 0.003). Conclusion: Within the first 24 h of hospital admission to a general medicine service, adverse hospitalization outcomes are rare and not associated with ED boarding.

1116: END-TIDAL CARBON DIOXIDE MONITORING FOR TRACHEAL INTUBATION

Introduction The new model in medical education of longitudinal clinical clerkships can be complemented by high-technology simulation, which provides a safe space for learners to consolidate clinical knowledge and practice decision-making skills, teamwork, and communication. We developed an interdisciplinary training intervention including a simulation case and structured debriefing to link clinical content between pediatrics and obstetrics at a major academic medical center. Methods In this case, a 38-year-old female at 38 weeks gestation presents with onset of labor complicated by shoulder dystocia. After the appropriate maneuvers, a depressed neonate is delivered and requires resuscitation. Major equipment needed includes a high- or low-technology birthing mannequin and an infant mannequin. Results Fifty-four third-year medical students participated in this simulation-based intervention at the completion of their integrated pediatrics and obstetrics clerkship. Ninety-one percent of students agreed that the shoulder dystocia simulation was designed appropriately for their learning level and enhanced their ability to handle a risky delivery. Ninety-four percent agreed that the neonatal resuscitation simulation was designed appropriately for their learning level, and 89% reported an enhanced ability to handle a similar situation in the clinic following the intervention. The average overall ratings were 4.24 (SD = 0.61) and 4.06 (SD = 0.89) on a 5-point scale (1 = poor, 5 = excellent) for the obstetrics and pediatrics simulations, respectively. Discussion The integrated obstetrics and pediatrics scenario is feasible to run and clinically accurate. Two distinct areas of medicine in the third-year curriculum are logically incorporated into one cohesive simulation-based training intervention that students found positive and realistic.

Paediatric community-acquired septic shock: results from the REPEM network study

Learning Objectives: Quantitative end-tidal carbon dioxide (qEtCO2) measurement with capnography device (CD) is becoming more available in pediatric ICUs and EDs. Yet CD utilization for confirmation of tracheal intubation (TI) is not known across variable pediatric ICUs and EDs. Clinical significance of CD use in detection of esophageal intubation, and prevention of acute desaturation (SpO2<80%) during TI are also unknown. We hypothesize that CD use to confirm TI success has become more common in both ICUs and EDs, and associated with lower occurrence of esophageal intubation with delayed recognition (DEI) and desaturation. Methods: Prospective multicenter cohort of a pediatric airway quality improvement database (NEAR4KIDS) between 7/2010 and 12/2015 was analyzed with inclusion criteria: age<18yr with initial TI. We evaluated the trend of CD use over time, and the association between CD use and the occurrence DEI/desaturation, while adjusting for patient, provider, location and clustering by site. Chi2 test for univariate analyses, multivariable logistic regression with GEE model, p<0.05 as significant. Results: Among 11,239 TIs (ICU:10,698, ED:541) from 34 sites, CDs were used in 45% in ICUs and 66% in EDs (p<0.001). CD use was significantly increased overtime in both locations (year 2015, ICU:52%, ED:73%, p<0.01 for trend at both locations). There was significant site variability in CD use (median 50%, IQR 25–85%, p<0.001). The use of a CD was less common in TI for respiratory failure (p<0.001) and by resident providers (p<0.001). DEI was reported in 0.44%; the occurrence was not different in TIs with/without a CD (with capnography 0.38% vs. without 0.48%, OR 0.78, p=0.34). Desaturations <80% were seen in 17% (with CD 16% vs. without CD 19%, OR 0.98, 95% CI: 0.96–0.99, p=0.003). Conclusions: There is large practice variation in CD use in pediatric ICUs and EDs. CD use was also significantly associated with fewer occurrences of desaturations, but not with DEI.