A National Simulation-Based Study of Pediatric Critical Care Transport Teams Performance.

OBJECTIVES: To assess pediatric critical care transport (CCT) teams' performance in a simulated environment and to explore the impact of team and center characteristics on performance. STUDY DESIGN: This observational, multicenter, simulation-based study enlisted a national cohort of pediatric transport centers. Teams participated in 3 scenarios: nonaccidental abusive head injury, sepsis, and cardiac arrest. The primary outcome was teams' simulation performance score. Secondary outcomes were associations between performance, center and team characteristics. RESULTS: We recruited 78 transport teams with 196 members from 12 CCT centers. Scores on performance measures that were developed were 89% (IQR 78-100) for nonaccidental abusive head injury, 63.3% (IQR 45.5-81.8) for sepsis, and 86.6% (IQR 66.6-93.3) for cardiac arrest. In multivariable analysis, overall performance was higher for teams including a respiratory therapist (0.5 points [95% CI: 0.13, 0.86]) or paramedic (0.49 points [95% CI: 0.1, 0.88]) and dedicated pediatric teams (0.37 points [95% 0.06, 0.68]). Each year increase in program age was associated with an increase of 0.04 points (95% CI: 0.02, 0.06). CONCLUSIONS: Dedicated pediatric teams, inclusion of respiratory therapists and paramedics, and center age were associated with higher simulation scores for pediatric CCT teams. These insights can guide efforts to enhance the quality of care for children during interfacility transports.

Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center.

OBJECTIVE: To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN: A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. RESULTS: A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. CONCLUSIONS: Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.

Improving Pediatric Readiness and Clinical Care in General Emergency Departments: A Multicenter Retrospective Cohort Study.

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

Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study.

OBJECTIVE: To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN: A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS: Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline. CONCLUSIONS: Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.