Decision making in continuing professional development organisations during a crisis.

INTRODUCTION: Early in COVID-19, continuing professional development (CPD) providers quickly made decisions about program content, design, funding and technology. Although experiences during an earlier pandemic cautioned providers to make disaster plans, CPD was not entirely prepared for this event. We sought to better understand how CPD organisations make decisions about CPD strategy and operations during a crisis. METHODS: This is a descriptive qualitative research study of decision making in two organisations: CPD at the University of Toronto (UofT) and the US-based Society for Academic Continuing Medical Education (SACME). In March 2021, using purposive and snowball sampling, we invited faculty and staff who held leadership positions to participate in semi-structured interviews. The interview focused on the individual's role and organisation, their decision-making process and reflections on how their units had changed because of COVID-19. Transcripts were reviewed, coded and analysed using thematic analysis. We used Mazmanian et al.'s Ecological Framework as a further conceptual tool. RESULTS: We conducted eight interviews from UofT and five from SACME. We identified that decision making during the pandemic occurred over four phases of reactions and impact from COVID-19, including shutdown, pivot, transition and the 'new reality'. The decision-making ability of CPD organisations changed throughout the pandemic, ranging from having little or no independent decision-making ability early on to having considerable control over choosing appropriate pathways forward. Decision making was strongly influenced by the creativity, adaptability and flexibility of the CPD community and the need for social connection. CONCLUSIONS: This adds to literature on the changes CPD organisations faced due to COVID-19, emphasising CPD organisations' adaptability in making decisions. Applying the Ecological Framework further demonstrates the importance of time to decision-making processes and the relational aspect of CPD. To face future crises, CPD will need to embrace creative, flexible and socially connected solutions. Future scholarship could explore an organisation's ability to rapidly adapt to better prepare for future crises.

Elements and Definitions of Continuing Professional Development Leadership: A Scoping Review.

INTRODUCTION: Leaders are being asked to transform the way that continuing professional development (CPD) is delivered to focus on better, safer, and higher quality care. However, there is scarce literature on CPD leadership. We set out to study what CPD leadership means and describe the competencies required for CPD leadership. METHODS: A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension guidelines for scoping reviews guidelines was conducted. With librarian support, four databases were searched for publications related to leadership, medical education, and CPD. Publications were screened by two reviewers and three reviewers extracted data. RESULTS: Among 3886 publications, 46 were eligible for a full-text review and 13 met the final inclusion criteria. There was no agreed upon definition of CPD leadership and variable models and approaches to leadership in the literature. Contextual issues shaping CPD (eg, funding, training, and information technology) are evolving. We identified several attitudes and behaviors (eg, strategic thinking), skills (eg, collaboration), and knowledge (eg, organizational awareness) important to CPD leadership, but no established set of unique competencies. DISCUSSION: These results offer the CPD community a foundation on which competencies, models, and training programs can build. This work suggests the need to build consensus on what CPD leadership means, what CPD leaders do, and what they will need to create and sustain change. We suggest the adaptation of existing leadership frameworks to a CPD context to better guide leadership and leadership development programs.

Perceived Advantages and Disadvantages of Online Continuing Professional Development (CPD) During COVID-19: CPD Providers' Perspectives.

INTRODUCTION: COVID-19 precipitated many CPD providers to develop new technology competencies to create effective online CPD. This study aims to improve our understanding of CPD providers' comfort level, supports, perceived advantages/disadvantages, and issues in technology-enhanced CPD delivery during COVID-19. METHODS: A survey was distributed to CPD providers at the University of Toronto and members of the Society for Academic Continuing Medical Education and analyzed using descriptive statistics. RESULTS: Of the 111 respondents, 81% felt very to somewhat confident to provide online CPD, but less than half reported IT, financial, or faculty development supports. The top reported advantage to online CPD delivery was reaching a new demographic; top disadvantages included videoconferencing fatigue, social isolation, and competing priorities. There was interest in using less frequently used educational technology such as online collaboration tools, virtual patients, and augmented/virtual reality. DISCUSSION: COVID-19 precipitated an increased comfort level in using synchronous technologies to provide CPD, giving the CPD community an increased cultural acceptance and skill level to build on. As we move beyond the pandemic, it will be important to consider ongoing faculty development, particularly toward asynchronous and HyFlex delivery methods to continue expand CPD reach and negate negative online experiences such as videoconferencing fatigue, social isolation, and online distractions.

The Ontological Choreography of Continuing Professional Development: A Mixed-Methods Study of Continuing Professional Development Leaders and Program Directors.

INTRODUCTION: Reports have forecast significant changes ahead for Continuing Professional Development (CPD). With new models on the horizon, CPD developers will require additional knowledge and training. Our objective was to learn how CPD leaders and developers came into their roles, if they are engaged in scholarship and the challenges and opportunities in pursuing scholarship. METHODS: We conducted a mixed grounded theory study, inviting CPD leaders within our institution for interviews focused on career paths, CPD and scholarly activities, networks, and supports and challenges. We invited 405 program/conference directors from our institution to participate in a survey focused on similar themes. We used the framework of ontological choreography in our final analysis. RESULTS: We conducted 13 interviews and had a survey response rate of 28.6% (n = 116). We identified three themes: (1) the pathway to becoming an expert in CPD planning and delivery is often unplanned, unclear, and uncredentialed; (2) CPD is undervalued as a field, with inadequate time and funding allocated; and (3) engagement with scholarship is variable while identifying resources to support scholarship is difficult. DISCUSSION: Beyond the usual calls for CPD to be more appropriately recognized and valued, this article offers another way to explore why past visions of the future have not been fully realized; CPD means different things to different people; it is ontologically different even across a single network in a single faculty.

Opioids Safety in Pediatric Procedural Sedation with Ketamine.

OBJECTIVE: To evaluate the effects of pre- and intraprocedural opioids on adverse events in children undergoing procedural sedation with ketamine in the emergency department (ED). STUDY DESIGN: We conducted a retrospective cohort study of all children aged 0-18 years who underwent procedural sedation with intravenous ketamine alone, or in combination with an opioid, at a tertiary-care pediatric ED between June 1, 2018, and August 31, 2020. We explored predictors of serious adverse events (SAEs), desaturation or respiratory intervention, and vomiting. RESULTS: Of 1164 included children (694 male, 59.6%; median age 5.0 years [IQR 2.0-8.0]), 80 (6.8%) vomited, 63 (5.4%) had a desaturation or required respiratory interventions, and 6 (0.5%) had SAEs. Pre- and intraprocedural opioids were not independent predictors of sedation-related adverse events. A concurrent respiratory illness (aOR 3.73; 95% CI 1.31-10.60, P = .01), dental procedure (aOR 3.05; 95% CI 1.25-7.21, P = .01), and a greater total ketamine dose (aOR 1.75; 95% CI 1.21-2.54, P = .003) were independent predictors of desaturation or respiratory interventions. A greater total ketamine dose (aOR 1.86; 95% CI 1.16-2.98, P = .01) and older age (aOR 1.15; 95% CI 1.07-1.24, P < .001), were independent predictors of vomiting. CONCLUSIONS: Pre- and intraprocedural opioids do not increase the likelihood of sedation-related adverse events. SAEs are rare during pediatric procedural sedation with ketamine in the ED.

Microlearning to improve CPD learning objectives.

BACKGROUND: Despite active involvement in teaching, clinical educators facilitating the continuing professional development (CPD) of their fellow specialists may not have formal training in medical education. Although required to write focused, measurable, topic-relevant, attainable and time-bound learning objectives to clearly inform learners on their learning intentions, CPD educators often receive no training on how to develop them. Microlearning is an online learning format occurring without real-time or interpersonal interaction, aiming to deliver easily accessible small units of focused information that are readily applicable for professionals. We hypothesised that Portuguese ophthalmologist educators lecturing to their fellow specialists would benefit from a microlearning experience (MLE) to improve the quality of their learning objectives. METHODS: We created an MLE about writing effective learning objectives. In phase 1, 25 clinical educators, scheduled to lecture at an ophthalmology conference in Portugal, were invited to watch the MLE, write and classify their learning objectives according to Bloom's modified taxonomy, and complete an evaluation survey. In phase 2, 86 clinical educators were invited to view the MLE and complete the survey. RESULTS: In phase 1, 20% of participants completed the exercise and survey. They categorised their objectives high on Bloom's taxonomy, considered the MLE useful and stated their intent to apply the principles learned in practice. In phase 2, 29% of participants provided feedback. All agreed that the intervention was clear and useful and 87% expressed an intent to use this information in their educational practice. CONCLUSIONS: The majority of participants found the MLE clear and useful. Further studies are necessary to measure the impact of the MLEs used by clinical educators.

The Use of Statistical Process Control Charts to Evaluate Interprofessional Education Sessions Embedded Into a Pediatric Emergency In situ Resuscitation Program.

STATEMENT: The rigorous evaluation of simulation in healthcare to improve resuscitations and team functioning can be challenging. Statistical process control (SPC) charts present a unique methodology to enable statistical rigor when evaluating simulation. This article presents a brief overview of SPC charts and its advantages over traditional before and after methodologies, followed by an exemplar using SPC to evaluate an in situ team training program with embedded interprofessional education sessions.

Concussion and its management: What do parents know?

OBJECTIVES: To determine the sensitivity of parental suspicion of concussion relative to paediatric emergency physicians in children who presented to an emergency department (ED) with a head injury. A secondary objective was to examine the variables associated with parental suspicion of concussion concordant with that of a physician. METHODS: Parents of children five to 18 years of age presenting to an urban paediatric ED with a nonstructural head injury completed a 24-item questionnaire. RESULTS: Of the 577 eligible parents, 495 (85.8%) consented to participate. The sensitivity of parental suspicion for concussion was 40.0% (95% CI 33.2% to 47.2%), while the specificity was 58.3% (95% CI 52.4% to 64.0%). The variable of child age ≥10 years was associated with an increased odds (OR 3.0) of a parental suspicion of concussion concordant with that of a physician; parent age, parent sex, mechanism of head injury and history of concussion in the child were not. Although 453 (91.5%) parents would stop activity if they believed their child sustained a concussion, only 159 (32.1%) were familiar with return-to-play guidelines. CONCLUSIONS: Parents often did not suspect a concussion when it was ultimately diagnosed by a paediatric emergency physician, although they were more likely to do so in older children. Only approximately one-third were aware of return-to-play guidelines. To enhance the potential for parent-driven advocacy in the recognition and management of concussion, these data support the need for increased parental education on this injury.

OBJECTIFS: Déterminer la sensibilité des soupçons des parents à l'égard des commotions cérébrales par rapport aux constatations des médecins d'urgence en pédiatrie auprès des enfants qui avaient consulté à l'urgence en raison d'une commotion cérébrale. Un objectif secondaire consistait à examiner les variables associées aux soupçons des parents à l'égard des commotions cérébrales qui concordaient avec les constatations d'un médecin. MÉTHODOLOGIE: Les parents d'enfants de cinq à 18 ans qui ont consulté dans une salle d'urgence pédiatrique en milieu urbain à cause d'une lésion cérébrale non structurelle ont rempli un questionnaire en 24 questions. RÉSULTATS: Sur les 577 parents admissibles, 495 (85,8 %) ont consenti à participer. La sensibilité des soupçons des parents à l'égard des commotions cérébrales s'élevait à 40,0 % (95 % IC 33,2 % à 47,2 %), tandis que la spécificité s'élevait à 58,3 % (95 % IC 52,4 % à 64,0 %). La variable de l'âge des enfants de dix ans ou plus s'associait à une plus forte possibilité (rapport de cote de 3,0) que les soupçons de commotion cérébrale des parents concordent avec les constatations du médecin. L'âge du parent, son sexe, le mécanisme de lésion cérébrale et des antécédents de commotion cérébrale chez l'enfant ne s'y associaient pas. Même si 453 parents (91,5 %) interrompraient les activités de leur enfant s'ils croyaient que celui-ci avait subi une commotion, seulement 159 (32,1 %) connaissaient les lignes directrices de retour au jeu. CONCLUSIONS: Souvent, les parents n'avaient pas soupçonné la commotion cérébrale dont leur enfant était victime avant qu'un médecin d'urgence en pédiatrie la diagnostique, mais ils étaient plus susceptibles de s'en douter chez des enfants plus âgés. Seulement environ le tiers connaissait les lignes directrices de retour au jeu. Pour accroître le potentiel de dépistage et de prise en charge des commotions cérébrales, ces données soutiennent la nécessité d'accroître l'éducation des parents à ce sujet.

The diagnosis of concussion in a pediatric emergency department.

OBJECTIVES: To compare the proportion of children diagnosed with a concussion by pediatric emergency physicians vs the proportion who met criteria for this injury as recommended by Zurich Fourth International Conference on Concussion consensus statement and to determine clinical variables associated with a physician diagnosis of a concussion. STUDY DESIGN: This was a prospective, cross-sectional study conducted at a tertiary care pediatric emergency department. We enrolled children ages 5 through 17 who presented with a head injury and collected data on demographics, mechanism of injury, head injury-related symptoms/signs, physician diagnosis, and discharge advice. RESULTS: We identified 495 children whose mean age was 10.1 years (SD 3.4 years); 308 (62.2%) were male. Emergency physicians diagnosed concussion in 200 (40.4%; 95% CI 36.1, 44.7) children, and 443 (89.5%; 95% CI 86.8, 92.2) met criteria for concussion in accordance with the Zurich consensus statement (P<.0001). Age≥10 years (OR 1.8), presentation≥1 day after injury (OR 2.4), injury from collision sports (OR 5.6), and symptoms of headache (OR 2.2) or amnesia (OR 3.4) were the variables significantly associated with an emergency physician's diagnosis of concussion. CONCLUSIONS: Pediatric emergency physicians diagnosed concussion less often relative to international consensus-based guidelines and used a limited number of variables to make this diagnosis compared with current recommendations. Thus, pediatric emergency physicians may be missing cases of concussion and the corresponding opportunity to provide critical advice for cognitive and physical management.

Pain in children: assessment and nonpharmacological management.

Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures.

Reducing distress for children during invasive procedures: randomized clinical trial of effectiveness of the PediSedate.

BACKGROUND: Procedural pain control remains problematic for young children, especially during anxiety-causing procedures for which children should not be deeply sedated. The PediSedate was designed to address this problem by delivering nitrous oxide in oxygen through a simple nosepiece, combined with an interactive video component, so that children can use attention and distraction with drug delivery. OBJECTIVES: We conducted a randomized clinical trial to evaluate the effectiveness of the PediSedate for reducing children's behavioral distress in comparison with standard care in the emergency department. Secondary objectives were to assess children's acceptance, cooperation, and pain. METHODS: Thirty-six children, aged 3-9 years old, who required invasive procedures associated with high levels of anxiety and low levels of pain such as sutures, IVs, and lumbar punctures were randomized to receive either the standard care or the PediSedate. The primary outcome was children's distress (observational scale of behavioral distress) that was monitored before and during the procedure. RESULTS: Children randomized to the PediSedate group had significantly less distress during invasive procedures (mean = 1.8, sd = 3.2) than children receiving standard care (mean = 9.3, SD = 5.6; anova, P < 0.0001). Also, children in the PediSedate group were more cooperative [chi(2)(1) = 22.05, P < 0.0001] and fewer children reported pain [chi(2)(1) = 14.45, P < 0.001]. CONCLUSIONS: Previous studies have demonstrated the effectiveness of nitrous oxide sedation alone for minimizing pain and distress during invasive procedures. We have found that delivering nitrous oxide sedation via a system combined with an interactive video component is also effective. Further studies should determine which factors are dominant and determine the specific failure rate for this delivery system in comparison with other systems.

Guidelines to practice: the process of planning and implementing a pediatric sedation program.

OBJECTIVE: Pediatric sedation practices vary among institutions and even within the same institution depending on providers and location. We planned to implement a pediatric procedural sedation program for a tertiary care pediatric emergency department to standardize sedation practices among emergency physicians. METHODS: An interactive contextual planning model was adapted, and several tasks were initiated simultaneously. The director of pediatric emergency medicine and clinical director of the institution approved the proposal for the sedation program. Needs assessment surveys and focus group interviews were conducted to identify educational needs of the target audience and infuse a sense of ownership. A grant was obtained from the institution because the budget exceeded available divisional funds. Other pediatric sedation guidelines and published literature were used to produce a sedation handbook and pocket card. Interim approval was obtained from the Drugs and Therapeutics Committee and the Patient Care Committee. RESULTS: The program was successfully implemented after all physicians and nurses working in the emergency department attended a half-day sedation course and completed a multiple-choice examination. Random chart audits verify that the emergency physicians are performing almost all procedural sedations now as per protocol. CONCLUSIONS: Implementing a structured program facilitates guideline adherence. Adapting a flexible contextual planning model was successful in translating guidelines to practice where resources were limited, and the target audience was highly trained adult learners.

Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines.

BACKGROUND: Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines. OBJECTIVE: Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning. METHODS: We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n = 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multifaceted sedation course before writing the multiple-choice examination. RESULTS: The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%-96.5%) was significantly higher (p < 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%-86.6%). CONCLUSION: The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.