Cara Doughty

Pediatric emergency medicine asynchronous e-learning: A multicenter randomized controlled solomon four-group study

OBJECTIVES Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. METHODS Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearsons correlation tested associations between module usage, scores, and ITE scores. RESULTS A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. CONCLUSIONS Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.

Simulation in Pediatric Emergency Medicine Fellowships.

BACKGROUND AND OBJECTIVES: Graduate medical education faces challenges as programs transition to the next accreditation system. Evidence supports the effectiveness of simulation for training and assessment. This study aims to describe the current use of simulation and barriers to its implementation in pediatric emergency medicine (PEM) fellowship programs. METHODS: A survey was developed by consensus methods and distributed to PEM program directors via an anonymous online survey. RESULTS: Sixty-nine (95%) fellowship programs responded. Simulation-based training is provided by 97% of PEM fellowship programs; the remainder plan to within 2 years. Thirty-seven percent incorporate >20 simulation hours per year. Barriers include the following: lack of faculty time (49%) and faculty simulation experience (39%); limited support for learner attendance (35%); and lack of established curricula (32%). Of those with written simulation curricula, most focus on resuscitation (71%), procedures (63%), and teamwork/communication (38%). Thirty-seven percent use simulation to evaluate procedural competency and resuscitation management. PEM fellows use simulation to teach (77%) and have conducted simulation-based research (33%). Thirty percent participate in a fellows’ “boot camp”; however, finances (27%) and availability (15%) limit attendance. Programs receive simulation funding from hospitals (47%), academic institutions (22%), and PEM revenue (17%), with 22% reporting no direct simulation funding. CONCLUSIONS: PEM fellowships have rapidly integrated simulation into their curricula over the past 5 years. Current limitations primarily involve faculty and funding, with equipment and dedicated space less significant than previously reported. Shared curricula and assessment tools, increased faculty and financial support, and regionalization could ameliorate barriers to incorporating simulation into PEM fellowships.

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management

Abstract Background: A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training. Objectives: The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs). Methods: This is a two-year retrospective cohort study of paramedics who transported 0–18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearsons χ2 test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous). Results: Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72–2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77–2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study. Conclusion: Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence. Key words: seizure; emergency medical services; simulation; pediatrics

A bullous lesion in a neutropenic adolescent.

Ecthyma gangrenosum (EG) is a cutaneous manifestation of bacteremia and has classically been associated with Pseudomonas aeruginosa sepsis. The major risk factor for EG is neutropenia, and it is important to recognize that infectious lesions in neutropenic patients may lack the classic inflammatory features of infection in normal hosts. Ecthyma gangrenosum can be the herald of severe sepsis in neutropenic children.

Pediatric Emergency Medicine Online Curriculum Improves Resident Knowledge Scores, But Will They Use It?

ObjectiveShift work on a pediatric emergency medicine (PEM) rotation makes didactic scheduling difficult, thereby limiting teaching opportunities. These constraints make this rotation an ideal setting to supplement resident education with an online curriculum. We aimed to determine if implementation of an online curriculum during a resident PEM rotation improves posttest performance and increases satisfaction with resident educational experience. MethodsThis was a prospective before/after study of pediatric and emergency medicine residents on a 1-month rotation in a tertiary care pediatric emergency department. A curriculum was developed consisting of 17 online modules. In the first 5 months of the study, 42 control residents received traditional bedside teaching. In the last 12 months, 80 intervention residents completed at least 8 modules during their rotation. Both groups completed a pretest at rotation start and a posttest and end-of-rotation survey at rotation end. ResultsControl group pretest and posttest scores were not significantly different. In the intervention group, posttest scores were significantly increased compared with pretest scores (68 vs 59, P < 0.01). A low percentage of residents completed the study. Only 42% of the 189 residents enrolled in the intervention group completed the posttest and 28% completed the survey. ConclusionsImplementing an online PEM curriculum significantly improved knowledge. As residency programs face new duty hour requirements, online curricula may provide an effective way to supplement teaching. However, to capitalize on this self-directed curriculum, the low participation rates in this study suggest we must first determine and establish ways to overcome barriers to online learning.

Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study.

Introduction Simulation-based medical education (SBME) improves medical knowledge compared with no intervention. In traditional SBME, more time is spent debriefing than practicing skills. Rapid cycle deliberate practice (RCDP) simulation allows learners to practice skills repetitively, receive brief interspersed feedback, and has been shown to improve individual performance of resuscitation skills in simulation; it has not been compared with traditional simulation methods. Objective The aim of the study was to compare traditional and RCDP SBME. Methods Four pediatric resuscitation cases (3 for teaching and 1 for testing) were developed. For the RCDP arm, traditional cases were deconstructed into sequences of progressively difficult rounds. The last RCDP round served as the traditional arm scenario. Learners received 1 type of instruction on 2 separate days. Pretest and posttest performance during simulation were video recorded and scored using the Simulation Team Assessment Tool; satisfaction surveys were collected. Results Pretest team performance was similar in both groups. Simulation Team Assessment Tool score improvement for RCDP was 7.2% (95% confidence interval, 3.4% to 11%) and traditional was 0.8% (95% confidence interval, −11% to 13%). The difference in improvement of the human factors subscore was statistically significant; RCDP improved 10.2% and traditional improved 1.7% (P = 0.013). The RCDP technique was well received by learners but caused fatigue. Conclusions This pilot study showed a trend toward greater improvement in team performance and significantly greater improvement for human factors with RCDP compared with traditional simulation. Future studies comparing RCDP with other methods are needed to identify best practices and applications of RCDP, including which learners and learning objectives are best suited to RCDP.

Initial Development of C.A.T.E.S.: A Simulation-Based Competency Assessment Instrument for Neonatal Nurse Practitioners.

Abstract Purpose: Determine content validity of global statements and operational definitions and choose scenarios for Competency, Assessment, Technology, Education, and Simulation (C.A.T.E.S.), instrument in development to evaluate multidimensional competency of neonatal nurse practitioners (NNPs). Design: Real-time Delphi (RTD) method to pursue four specific aims (SAs): (1) identify which cognitive, technical, or behavioral dimension of NNP competency accurately reflects each global statement; (2) map the global statements to the National Association of Neonatal Nurse Practitioners (NANNP) core competency domains; (3) define operational definitions for the novice to expert performance subscales; and (4) determine the essential scenarios to assess NNPs. Sample: Twenty-five NNPs and nurses with competency and simulation experience Main outcome variable: One hundred percent of global statements correct for competency dimension and all but two correct for NANNP domain. One hundred percent novice to expert operational definitions and eight scenarios chosen. Results: Content validity determined for global statements and novice to expert definitions and essential scenarios chosen.

A novel mechanism for simulation of partial seizures in an infant.

Introduction Seizures are a common pediatric emergency, occurring in 4% to 6% of all children by the age of 16 years. Seizures are also present in many patients with critical illness requiring resuscitation. Whereas some high-fidelity simulators have built-in seizure mechanisms, others do not. We report a novel inexpensive mechanism replicating a partial seizure in the SimBaby mannequin and the use of this mechanism in several high-fidelity in situ simulations. Methods A brake lever set and a brake cable/housing for a mountain bike were attached under the skin of the SimBaby mannequin, through the groin, out of the axilla, and around the left arm. The cable was hidden under sheets and taped to the floor. The cable length allowed the controller to be several feet away from the mannequin while controlling the seizures. In our emergency department in situ simulations, this person is the educator who runs the mannequin or a confederate participating in the scenario. Results The instructor controlling the seizure mechanism was able to stand unobtrusively in the corner during the in situ simulations and activate the seizure as indicated. Simulation participants clearly recognized that the infant was seizing and reacted appropriately as per the scenario (status epilepticus, head trauma, and tricyclic antidepressant ingestion). Conclusions We report a novel and inexpensive mechanism to accurately simulate partial seizures, using commonly available inexpensive bicycle components.

Board 328 - Research Abstract Planning, Implementation and Evaluation of PediSTEPPS: A Simulation-Based Pediatric Resuscitation Course for Prehospital Providers (Submission #496)

Introduction/Background Prehospital providers rarely manage critically ill pediatric patients.1-3 Ongoing pediatric resuscitation education is critical to maintaining provider knowledge and skills. However, numerous barriers limit prehospital providers access to pediatric continuing education.2 Simulation-based education is ideally suited to resuscitation education and it has been used to identify performance deficiencies in paramedics for planning follow-up educational interventions.4,5 Methods A consensus group of experts in simulation, medical education, pediatric emergency medicine (PEM), prehospital pediatrics and emergency medical services (EMS) convened to develop goals and objectives for the course, focused on unique aspects of pediatric assessment, management, hands-on skills and teamwork in high-fidelity resuscitation scenarios. Detailed course materials were developed including lectures, skills station guides, high-fidelity scenario goals and objectives, manikin programs, scripted debriefings, debriefing checklists and confederate roles. Planned evaluations included pre and post-tests, self-efficacy checklists and a course satisfaction survey. All course materials were congruent with the prehospital protocols and scope of practice for the Emergency Medical Technician (EMT) - basic and paramedic provider levels of the City of Houston Fire Department (HFD) EMS. HFD EMS and PEM instructors were trained to teach PediSTEPPS. After initial curriculum development and instructor training, the curriculum was trialed with HFD EMS providers and then modified based on their feedback and the feedback of the HFD EMS medical directors. Results To date, PediSTEPPS has been taught for 8 months to a total of 209 participants. EMT-B pre and post-test scores increased from 64.4 % (95% CI: 62.3-66.5%) to 75.2% (95% CI: 73.6-76.9%) (p<0.001). They also increased from 68.3% (95% CI: 65.9-70.7%) to 80.2% (78.2-82.1%) for EMT-Ps (p<0.001). On a 5 point Likert scale (1 = strongly disagree; 5 = strongly agree), the mean participant ratings were as follows: “Simulation is the appropriate methodology to teach this material,” mean = 4.70 (range 2-5); “The course was appropriate for my level of learning,” mean = 4.64 (range 1-5); “This course has improved my clinical knowledge,” mean = 4.70 (range 3-5); and “I plan to apply what I learned here to my clinical practice,” mean 4.81 (range 3-5). The lowest satisfaction was with “The simulation center environment is realistic to my clinical environment,” mean = 4.28 (range 1-5). Conclusion Multidisciplinary collaboration between simulation-based medical educators, PEM physicians and EMS providers is feasible. PediSTEPPS significantly improved provider knowledge scores immediately after completion of the course for both EMT-B and EMT-P providers. Implementing a simulation-based pediatric resuscitation course with consideration of EMT-Basic and paramedic level providers scope of practice is associated with high learner satisfaction. Simulating a realistic prehospital environment remains challenging. Future work will evaluate knowledge and skills retention, self-efficacy and clinical performance. References 1. Gausche M, Henderson DP, Seidel JS. Vital Signs as Part of the Prehospital Assessment of the Pediatric Patient: A Survey of Paramedics. Annals of Emergency Medicine. 1990; 19(2): 173-178. 2. Glaeser PW, Linzer J, Tunik MG, Henderson DP, Ball J. Survey of Nationally Registered Emergency Medical Services Providers: Pediatric Education. Annals of Emergency Medicine. 2000; 36(1): 33-38. 3. Graham CJ, Stuemky J, Lera TA. Emergency Medical Services Preparedness for Pediatric Emergencies. Pediatric Emergency Care. 1993; 9(6): 329-331. 4. Miller DR, Kalinowski EJ, Wood D. Pediatric continuing education for EMTs: Recommendations for content, method, and frequency. Pediatric Emergency Care 2004; 20(4): 269-272. 5. Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic resuscitation skills. Prehospital Emergency Care 2009;13:345-356. Disclosures Laerdal Foundation for Acute Medicine Cord Blood Registry- non simulation related.

Progressive Unilateral Arm Weakness in a 7-Year-Old Boy

A child with joint or extremity pain is a common presentation to the emergency department. Often, there is some element to the patients history, whether it is trauma or some other significant history, which leads to a likely diagnosis. When there is a history of fever and progressive arm weakness, an astute emergency physician would have heightened awareness of a possible systemic process. We describe a case of unilateral shoulder pain with associated fever in a 7-year-old boy who presented to the emergency department with progressive arm weakness to the same side.