Pediatric Emergency Department Staff Research Articles

Developing a Sustainable Need-Based Pediatric Acute Care Training Curriculum in Solomon Islands.

The Johns Hopkins Hospital Pediatric Emergency Department (PED) was invited to collaborate with the National Referral Hospital (NRH), Solomon Islands, to establish an acute care pediatric education program for the country's inaugural class of national medical graduate trainees. To develop and evaluate a sustainable, need-based post-graduate training curriculum in pediatric acute care, resuscitation, and point-of-care ultrasound. A need-based training curriculum was developed utilizing the ADDIE model and was implemented and revised over the course of 2 years and two site visits. Implementation followed a train-the-trainer model. The curriculum consisted of high-yield didactics including workshops, simulations, hands-on ultrasound sessions, and lectures at the NRH. A mixed-methods design was used to evaluate the curriculum, including pre/posttesting, qualitative group discussions, and individual surveys. The curriculum was revised in response to ongoing learner evaluations and needs assessments. Continuing educational sessions after the site visit demonstrated sustainability. The curriculum included 19 core topics with 42 teaching sessions during the two site visits. A total of 135 pre/posttests and 366 individual surveys were collected from 46 trainees. Completion rates were 78.2% for surveys and 71.3% for pre/posttests. Pre/posttest scores increased from 44 to 63% during the first site visit and 69.6 to 77.6% during the second. Learners reported a mean 4.81/5 on a standard Likert scale for curriculum satisfaction. Group discussions and surveys highlighted key areas of knowledge growth, important clinical care advances, and identified further needs. Initial sustainability was demonstrated by continued ultrasound sessions led by local graduate trainees. A collaborative team including Johns Hopkins PED staff, Solomon Islands' graduate trainees, and NRH administration initiated a professional education curriculum for the first class of Solomon Islands' medical graduates. Knowledge growth and positive impacts of the program were reflected in learner survey and test scores. Graduate trainees were identified as local champions to continue as course instructors. This innovative curriculum was developed, revised, and initially sustained on site. It has been successful in introducing life-saving pediatric acute care and graduate training in Solomon Islands.

A Brief Structured Educational Curriculum Improves Pediatric Emergency Department Staff’s HAZMAT Response Skills

A Brief Structured Educational Curriculum Improves Pediatric Emergency Department Staff’s HAZMAT Response Skills

Impact of a disaster preparedness training programme on health staff

Abstract Objectives The aim of this study is to evaluate the effectiveness of a disaster preparedness training programme in a Paediatric Emergency Department (PED). Methods A quasi-experimental study was conducted using an anonymous questionnaire that was distributed to health care providers of a PED in a tertiary paediatric hospital. The questions concerned the disaster plan (DP), including theoretical and practical aspects. Questionnaires were distributed and completed in January 2014 (period 1) and November 2014 (period 2). The disaster training programme includes theoretical and practical sessions. Results A total of 110 questionnaires were collected in period 1, and 80 in period 2. Almost three-quarters (71.3%) of PED staff attended the theoretical sessions, and 43.8% attended the practical sessions. The application of this training programme significantly improved knowledge about the DP, but no improvement was observed in the practical questions. PED staff felt more prepared to face a disaster after the training programme (15.5% vs. 41.8%, P Conclusions The training programme improved some knowledge about the disaster plan, but it has not improved responses in practical situations, which may be due to the low attendance at practical sessions and the time between the training programme and the questionnaires.

Impacto de un programa de formación de catástrofes en el personal sanitario

ObjectivesThe aim of this study is to evaluate the effectiveness of a disaster preparedness training program in a Paediatric Emergency Department (PED). MethodsA quasi-experimental study was conducted using an anonymous questionnaire that was distributed to health care providers of a PED in a tertiary paediatric hospital. The questions concerned the disaster plan (DP), including theoretical and practical aspects. Questionnaires were distributed and completed in January 2014 (period 1) and November 2014 (period 2). The disaster training program includes theoretical and practical sessions. ResultsA total of 110 questionnaires were collected in period 1, and 80 in period 2. Almost three-quarters (71.3%) of PED staff attended the theoretical sessions, and 43.8% attended the practical sessions. The application of this training program significantly improved knowledge about the DP, but no improvement was observed in the practical questions. PED staff felt more prepared to face a disaster after the training program (15.5% vs. 41.8%, P<.001). ConclusionsThe training program improved some knowledge about the disaster plan, but it has not improved responses in practical situations, which may be due to the low attendance at practical sessions and the time between the training program and the questionnaires.

Evaluation of an initiative to reduce radiation exposure from CT to children in a non-pediatric-focused facility.

We would like to share our experience of reducing pediatric radiation exposure. Much of the recent literature regarding successes of reducing radiation exposure has come from dedicated children's hospitals. Nonetheless, over the past two decades, there has been a considerable increase in CT imaging of children in the USA, predominantly in non-pediatric-focused facilities where the majority of children are treated. In our institution, two general hospitals with limited pediatric services, a dedicated initiative intended to reduce children's exposure to CT radiation was started by pediatric radiologists in 2005. The initiative addressed multiple issues including eliminating multiphase studies, decreasing inappropriate scans, educating referring providers, training residents and technologists, replacing CT with ultrasound or MRI, and ensuring availability of pediatric radiologists for consultation. During the study period, the total number of CT scans decreased by 24 %. When accounting for the number of scans per visit to the emergency department (ED), the numbers of abdominal and head CT scans decreased by 37.2 and 35.2 %, respectively. For abdominal scans, the average number of phases per scan decreased from 1.70 to 1.04. Upon surveying the pediatric ED staff, it was revealed that the most influential factors on ordering of scans were daily communication with pediatric radiologists, followed by journal articles and lectures by pediatric radiologists. We concluded that a non-pediatric-focused facility can achieve dramatic reduction in CT radiation exposure to children; however, this is most effectively achieved through a dedicated, multidisciplinary process led by pediatric radiologists.

Risk factors for apnea in children presenting with out-of-hospital seizure.

This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-hospital seizure. This is a retrospective study of pediatric patients with seizure transported by paramedics to the pediatric emergency department (PED) of a tertiary center from July 2008 to June 2009. Patients with traumatic injury and those with another diagnosis after PED evaluation were excluded. We evaluated the effect of field diazepam and other potential risk factors on the occurrence of apnea, defined as the need for airway management, that is, bag-mask ventilation by paramedics or bag-mask ventilation or intubation by PED staff within 30 minutes of arrival. There were 336 pediatric patients meeting inclusion criteria. The median age was 1.9 years (interquartile range,1.3-3.0 years); 193 patients (57%) were male. Fifty-four patients (16%) were treated with diazepam before PED arrival. There were 28 apneic events (8.3%). The adjusted relative risk for apnea given diazepam in the field by any route was 10.2 (95% confidence interval, 3.9-21.8; P < 0.0001), adjusted for age and seizure on arrival. Persistent seizure on PED arrival was also highly associated with apnea, with an adjusted relative risk of 15.8 (95% confidence interval, 6.5-28.9; P < 0.0001). Field treatment with diazepam and seizing at the time of PED arrival are associated with the occurrence of apnea in children 0 to 5 years of age with out-of-hospital seizure. Larger studies are needed to determine what other factors may contribute to this risk.

Risk Factors for Apnea in Pediatric Patients Transported by Paramedics for Out-of-Hospital Seizure

Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.

Family Presence During Invasive Procedures at the Emergency Department

Family presence (FP) during invasive procedures (IPs) in children remains controversial among pediatric emergency department (PED) staff. The authors aimed to determine health care providers' attitudes toward FP during IPs in Spain, to learn whether parents are given the option of being present during different IPs, and to study which factors influence the providers' opinions. Observational study. Physicians and nurses were asked to answer a questionnaire, which was sent to 43 PEDs and was available at the Spanish Pediatric Emergency Society Web site. We obtained 222 questionnaires from 36 Spanish hospitals. A total of 65.8% of the surveys were answered by physicians (66.4% pediatricians) and 34.2% by nurses. The median age of the respondents was 32 years, and 69.2% were women. Parents were given the option of being present during blood sampling (36.4%), intravenous line placement (32.7%), urethral catheterization (32.1%), lumbar puncture (13.5%), and resuscitation (1%). More than 60% of providers approved of FP during blood sampling, sutures, intravenous line placement, and urethral catheterization; however, only 10.8% of providers encourages FP during resuscitation. Against FP, health care staff argue procedural invasiveness (75.6%), parents' anxiety (87.6%), and worsened performance of the procedure (66%). Commonly expressed advantages were reducing patient distress (72.9%) and parent anxiety (62.3%). Physicians, especially the older ones, are more likely to encourage FP than nurses for some IPs. The PED staff tend to prefer parents not to be present during IPs as the level of invasiveness increases. Family presence is not common in Spanish PEDs. Older physicians are more likely to support FP than nurses.

Computer Modeling of Patient Flow in a Pediatric Emergency Department Using Discrete Event Simulation

Increasing patient census and department overcrowding are universal concerns in pediatric emergency medicine. Accurate predictions of patient flow and resource utilization in the pediatric emergency department (PED) are important in determining what aspects of PED activity could be modified to improve patient flow, reduce patient waiting times, and increase staff efficiency and morale, and thus direct change more effectively. We report (1) the construction of a Patient Flow Model (PFM) using discrete event simulation to test simulated PED staffing scenarios that were designed to alleviate the pressures that result from increased census and overcrowding, and (2) a Physician Scheduling Analysis Tool to assist in physician scheduling. Arena discrete event simulation modeling software was used to develop a model of PED patient flow after extensive interviews with PED staff and direct observation of patient flow in July 2005. A total of 517 patients were directly observed, and all modeled aspects of their interaction with PED staff and resources were recorded. Historical demographic patient arrival information was combined with observed patient flow data to provide simulated patient arrival rates for the PFM and was also used to construct the Physician Scheduling Analysis Tool. Validation of the PFM was performed by comparing annual simulated patient flow data with actual patient flow data. Previously determined staffing scenarios were applied to the simulation and the resulting performance indicator outputs examined. The PFM was validated on model-wide and process-specific levels, with excellent validation observed on high acuity-patient length of stay and for highly detailed processes such as triage and registration. Simulation of the addition of a hospital volunteer and a second triage nurse demonstrated reductions in pretriage waiting time and the proportion of patients waiting longer than 30 or 60 minutes for pretriage. Simulation of an extra physician shift to the staff schedule demonstrated reductions in length of stay for patients of all triage categories. The PFM accurately represents patient flow through the department and can provide simulated patient flow information on a variety of scenarios. It can effectively simulate changes to the model and its effects on patient flow.

Paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome

Objectives: To determine paediatric emergency department (ED) staff perceptions of the effectiveness and practice of infection control measures against a novel virulent pathogen. Methods: All medical staff of the paediatric...

Nonurgent Use of a Pediatric Emergency Department

To understand patterns of decision making among families presenting to a pediatric emergency department (ED) for nonacute care and to understand pediatric ED staff responses. Cross-sectional qualitative study using in-depth interviews, direct observations, and nonidentifying demographic data. Eleven percent of visits made during the study period were identified as nonacute. All were made by families from low-income areas. Three main themes emerged: (1) most families had been referred by their primary care providers; (2) the complexity of living in low-income areas makes the ED a choice of convenience for these stressed families; and (3) mistrust of primary health services was not identified by our respondents as a motivator for ED utilization, in contrast with other published data. Two themes emerged from ED staff: (1) actual nonurgent visit rates were lower than staff estimates; and (2) these visits produced frustration among staff members, although their degrees of insight and understanding of factors motivating these visits were variable. In this setting, nonacute visits occurred with lower than perceived frequency and caused disproportionate frustration among staff and families. These visits appear to be driven more by consequences of system design and structure than by family members' decision making. Mistrust of primary care services was not a strong family decision-making factor; the study's setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care.

Evaluation of a Curriculum for Intimate Partner Violence Screening in a Pediatric Emergency Department

We sought to describe the assessment of course participant changes in attitudes, self-efficacy, and behaviors after completion of the Its Time to Ask training curriculum for screening for intimate partner violence (IPV) in a pediatric emergency department (PED). A 22-item Likert scale questionnaire was administered at baseline (before training), after training, and at 6-month follow-up to PED employee participants in a 2-hour IPV education program. Mean participant responses were compared between baseline/posttraining and baseline/6-month follow-up. Participants also completed a course-satisfaction survey. A total of 79 PED staff completed the baseline questionnaire before the training. Eighty-seven participants completed the posttraining questionnaire, and 48 completed the 6-month follow-up questionnaire. Participants had consistent, positive changes in attitudes after training that persisted at the 6-month follow-up for 5 items on the questionnaire. Attitudes that did not change showed baseline means already in disagreement with questionnaire statements. Participants reported significant, positive changes for all 7 self-efficacy statements at 1 or both of the posttraining evaluations. The only changes in behavior were observed at 6 months. The majority of participants were satisfied with the training and would recommend it to colleagues. Significant, self-reported changes in attitudes, self-efficacy, and behaviors/clinical practice regarding screening for IPV in a PED can be achieved through participation in a brief training curriculum.

28 Paediatric Emergency Department Staff Perceptions of Infection Control Measures against Severe Acute Respiratory Syndrome

Severe Acute Respiratory Syndrome (SARS) is a respiratory illness recognized on several continents. Our city is one of the first major centres affected by SARS prompting the government to mandate rigorous infection control measures. Health care workers' perceptions of the effectiveness and practice of infection control measures during an evolving outbreak are previously unreported. The purpose of this study was to determine Paediatric Emergency Department (PED) staff perceptions of the effectiveness and practice of infection control measures against Severe Acute Respiratory Syndrome. All medical staff of the PED in a tertiary medical centre completed a written questionnaire over 7 days near the onset of the SARS outbreak. At the time of study, the effectiveness of infection control measures against this new pathogen was unknown. Level of concern regarding SARS and perceptions of the effectiveness and use of infection control measures were assessed on a 5-point scale. Statistical analysis was performed with SPSS using Chi-square and ANOVA tests with significance at p<0.05. Response rate was 97% (116/120). Using isolation rooms (mean score 4.6/5), wearing a mask when examining patients (4.5/5) and handwashing (4.5/5) were considered most effective. Staff physicians reported more handwashing than nurses and trainees (4.9/5 vs 4.5/5 and 4.5/5, p<0.05) while other measures were reported equally. Those who considered SARS a high public health threat reported higher compliance with handwashing (4.8/5 vs 4.4/5), wearing a mask at all times in the PED (3.9/5 vs 3.2/5), and gloves (3.6/5 vs 2.9/5) (p<0.05), but not eye protection (3.4/5 vs 3.0/5), gown use (4.9/5 vs 4.7/5), or wearing a mask when examining patients (5.0/5 vs 4.8/5) (p=NS). Staff who considered combined infection control measures effective in protecting patients and health care workers did not report increased compliance (p=NS). PED staff perceived some infection control measures to be more effective than others in protecting against the spread of SARS, and perceptions differed among staff physicians, nurses, and trainees. Eye protection was perceived as only moderately effective in protecting against the spread of SARS and reported compliance was relatively poor among PED staff. Concern of SARS as a public health threat rather than perceived effectiveness of infection control measures appears to have a greater impact on compliance.

Latex allergy in pediatric emergency department personnel.

Allergy to natural latex proteins has been recently recognized as a dangerous entity among health care professionals. Cutaneous symptoms related to latex glove use vary from the redness and scaling of contact dermatitis to urticaria. In addition, anaphylactic reactions have been reported. We report the spectrum of reactions to latex glove use in 93 members of our emergency department (ED) staff during a one-month study period. In addition, we attempt to correlate these symptoms with serologic evidence of atopy and latex allergy. Eighty-four of these subjects underwent total serum immunoglobulin E and latex-specific radioallergosorbent test (RAST) testing. Fifty-four percent of subjects reported symptoms relating to latex glove use, categorized as either contact dermatitis (48.4%) or urticaria (5.4%). Of the urticaria group, two subjects reported additional symptoms related to latex glove use such as rhinitis, conjunctivitis, or sneezing. All three groups of subjects (asymptomatic, contact dermatitis, and urticaria) were alike with respect to age, sex, and race. The urticaria group reported a higher incidence of environmental allergies (chi 2, P = 0.02). Serum total immunoglobulin E levels and latex-specific RAST results did not differ among the three groups. The one subject with a positive latex-specific RAST reported urticarial and nasoocular symptoms when exposed to latex gloves. Seventeen percent of symptomatic subjects reported decreased use of latex gloves because of these symptoms. It was concluded that many members of our pediatric ED staff exhibit a sensitivity to latex antigens. Clinical symptoms, rather than serologic testing, must be used to identify latex-sensitive individuals in this setting. Recommendations are offered to assist in the identification and management of hospital personnel who exhibit allergy to latex-containing products.