A Brief, Just-in-Time Sedation Training in the Pediatric Emergency Department Improves Performance During Adverse Events Encountered in Simulated Procedural Sedations.

BACKGROUND: Procedural sedation (PS) is commonly performed in emergency departments (EDs) by nonanesthesiologists. Although adverse events (AEs) are rare, providers must possess the clinical skills to react in a timely manner. We previously described residents' experience and confidence in PS as part of a needs assessment. We found that their ability to perform important clinical tasks as a result of the usual training experience demonstrates educational needs. We developed an educational intervention to address the deficiencies uncovered during our needs assessment. OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' clinical performance and confidence when faced with an AE during a simulated PS. METHODS: This was a prospective observational cohort study of residents at a tertiary care children's hospital. All ED attending physicians and fellows were trained in uniform delivery of the educational intervention, which was delivered extemporaneously at the bedside ("Just-in-Time" [JIT]) to all residents performing PS on actual patients in the pediatric ED, over the course of 1 year. Subjects completed the following both before and after the educational intervention: a survey pertaining to confidence in PS, followed by a standardized, video-recorded simulated PS complicated by apnea and desaturation. Clinical performance was evaluated and assessed both in real time and by a video-rater blinded to participants' year of training. We summarized baseline resident characteristics, confidence questionnaire item rankings and success in both the preparation and AE tasks. We compared successful task completion and time to task completion before and after intervention. RESULTS: Forty residents completed both the PRE and POST phases of the study. There was significant improvement in the proportion of residents who completed both preparation and AE tasks after the JIT training. Specifically, there was a significant improvement in the proportion of residents who performed positive-pressure ventilation to treat an apneic event associated with desaturation during the PS (P = 0.007). Residents' confidence scores also significantly improved after the training. CONCLUSION: A brief JIT training in the pediatric ED improves resident clinical performance and confidence when faced with an AE during a simulated PS. Future direction includes correlating this improved performance with patient outcomes in PS.

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation.

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2-5) to 6 (IQR 4-7) following SST (p < 0.0009, median difference 2, 95% CI 1-3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

Death of a Simulated Pediatric Patient: Toward a More Robust Theoretical Framework.

INTRODUCTION: A theoretical framework was recently proposed that encapsulates learner responses to simulated death due to action or inaction in the pediatric context. This framework, however, was developed at an institution that allows simulated death and thus does not address the experience of those centers at which this technique is not used. To address this, we performed a parallel qualitative study with the intent of augmenting the initial framework. METHODS: We conducted focus groups, using a constructivist grounded theory approach, using physicians and nurses who have experienced a simulated cardiac arrest. The participants were recruited via e-mail. Transcripts were analyzed by coders blinded to the original framework to generate a list of provisional themes that were iteratively refined. These themes were then compared with the themes from the original article and used to derive a consensus model that incorporated the most relevant features of each. RESULTS: Focus group data yielded 7 themes. Six were similar to those developed in the original framework. One important exception was noted; however, those learners not exposed to patient death due to action or inaction often felt that the mannequin's survival was artificial. This additional theme was incorporated into a revised framework. DISCUSSION: The original framework addresses most aspects of learner reactions to simulated death. Our work suggests that adding the theme pertaining to the lack of realism that can be perceived when the mannequin is unexpectedly saved results in a more robust theoretical framework transferable to centers that do not allow mannequin death.

Should Medical Errors Be Disclosed to Pediatric Patients? Pediatricians' Attitudes Toward Error Disclosure.

OBJECTIVE: Limited data exist on medical error disclosure in pediatrics. We sought to assess physicians' attitudes toward error disclosure to parents and pediatric patients. METHODS: An anonymous survey was distributed to 1200 members of the American Academy of Pediatrics. Surveys included 1 of 4 possible cases that only varied by patient age (16 or 9 years old) and by whether the medical error resulted in reversible or irreversible harm. Statistical analyses included chi-square, Bonferroni-adjusted P values, Fisher's exact test, Wilcoxon signed rank test, and logistic regressions including key demographic factors, patient age, and error reversibility. RESULTS: The response rate was 40% (474 of 1186). Overall, 98% of respondents believed it was very important to disclose medical errors to parents versus 57% to pediatric patients (P < .0001). Respondents believed that medical errors could be disclosed to developmentally appropriate pediatric patients at a mean age of 12.15 years old (SD 3.33), but not below a mean age of 10.25 years old (SD 3.55). Most respondents (72%) believed that physicians and parents should jointly decide whether to disclose to pediatric patients. When disclosing to pediatric patients, 88% of respondents believed that physicians should disclose with the parents present. Logistic regressions found only patient age (odds ratio 18.65, 95% confidence interval 9.20-37.8) and error reversibility (odds ratio 2.90, 95% confidence interval 1.73-4.86) to affect attitudes toward disclosure to pediatric patients. Respondent sex, year of medical school graduation, and area of practice had no effect on disclosure attitudes. CONCLUSIONS: Most respondents endorse disclosing medical errors to parents and older pediatric patients, particularly when irreversible harm occurs.

Assessing pediatric residents' clinical performance in procedural sedation: a simulation-based needs assessment.

OBJECTIVES: Our primary objective in this study was to perform a needs assessment of clinical performance during simulated procedural sedation (PS) by pediatric residents. Our secondary objective was to describe reported experience and confidence with PS during pediatric residency. METHODS: In this prospective observational cohort study, pediatric residents completed a survey of 15 Likert-scaled items pertaining to confidence in PS, followed by performance of a standardized, video-recorded simulated PS complicated by an adverse event (AE): apnea and desaturation. Clinical performance was evaluated according to an expert consensus-derived checklist of critical tasks. The difference in reported confidence between postgraduate years (PGY) was assessed by one-way analysis of variance (ANOVA); clinical checklist items were quantified descriptively. RESULTS: A total of 35 PGY-1, 39 PGY-2, and 7 PGY-3 residents participated. The most frequently completed tasks by all residents are ensuring the cardiorespiratory monitor (73%) and connecting the oxygen tubing (70%) during the preparation phase and recognizing AE (97%) and administering oxygen (95%) during the AE phase. Tasks that were completed infrequently by all residents include ensuring that the shoulder roll is available (11%) and ensuring access to head-of-bed (31%) during the preparation phase and applying shoulder roll (10%) and calling for help (23%) during the AE phase. The median time to recognition of AE from onset of hypoventilation was 33 seconds and that for delivery of oxygen and PPV was 60 and 97 seconds, respectively. Median confidence scores increased by PGY (PGY-1, 2; PGY-2, 3; PGY-3, 4; ANOVA F2,82 = 75, P< 0.0001). CONCLUSIONS: Significant differences exist in the reported confidence and observed performance among PGY levels during simulated PS. Resident performance on this checklist demonstrates educational needs in PS training. A curriculum in PS for pediatric residents should focus on reviewing preparation steps, equipment, and potential interventions should an AE occur.

Management of neonates with hyperbilirubinemia: improving timeliness of care using a clinical pathway.

BACKGROUND: Neonatal hyperbilirubinemia is a common reason for neonates to present to the emergency department (ED). Although clinical practice guidelines provide recommendations for evaluation and therapy, few studies have evaluated ways to apply them effectively in the ED setting. The primary objective of this study was to compare time to phototherapy in neonates presenting to the ED with jaundice before and after implementation of a nursing-initiated clinical pathway. Secondary outcomes included time to bilirubin result and ED length of stay in neonates. METHODS: We performed a retrospective historical control study comparing neonates presenting to the ED with jaundice during 9-month periods before and after initiation of the pathway. Charts were abstracted for times of assessment and treatment and final disposition. RESULTS: Three hundred neonates were included in this study: 149 before and 151 after pathway implementation. Median time to phototherapy (historical control: 128 minutes vs postintervention group: 52 minutes; P < .001), median time to bilirubin result (157 vs 99; P < .001), and median ED length of stay (268 minutes vs 195 minutes; P < .001) were shorter for neonates treated after the implementation of the clinical pathway. No complications were reported during the study period. CONCLUSIONS: After implementation of a clinical pathway for the management of neonates with jaundice in the ED, we observed a reduction in time to phototherapy, time to bilirubin measurement, and overall length of stay.

Ectopic atrial tachycardia in an infant with transient erythroblastopenia of childhood.

Transient erythroblastopenia of childhood is a self-limited anemia occurring in previously healthy children, secondary to temporary cessation of erythrocyte production. Although the precise etiology is unclear, most cases are associated with a viral illness. The anemia may be severe, with associated pallor, tachypnea, and tachycardia; treatment is supportive. We present an unusual case of a child with viral-induced transient erythroblastopenia of childhood and associated ectopic atrial tachycardia, requiring therapy with antiarrhythmics.

Cholelithiasis in a toddler with sickle cell disease.

Cholelithiasis is rarely seen in toddlers and school-aged children, even in the setting of sickle cell anemia. In addition to more common etiologies, such as gastroenteritis, constipation, and urinary tract infection, the differential diagnoses of acute abdominal pain in young children with sickle cell disease include vaso-occlusive pain crisis and splenic sequestration. We describe a case of a toddler with sickle cell disease initially presenting with abdominal pain who was found to have symptomatic cholelithiasis.

Spontaneous gastric perforation in a child with heterotaxy syndrome.

Gastric perforation is a potentially fatal condition that is rare in infants and children. Most case reports in the pediatric population are of neonates or in patients with various associated risk factors including prematurity, ischemia, trauma, or ulcers. Heterotaxy syndrome is characterized by abnormal symmetry and malposition of the thoracoabdominal organs and vessels. Spontaneous gastric perforation has not previously been reported in a child with heterotaxy syndrome. We present a case of a child with heterotaxy syndrome who presented with spontaneous gastric perforation. We review the signs and the symptoms, radiographic clues, and diagnostic considerations of gastric perforation.