Pediatric Emergency Medicine Physicians Research Articles

68 Pediatric Emergency Physician Burnout During the COVID-19 Pandemic: The Effect of Perfectionism

Emergency physicians are at risk of experiencing burnout and the COVID-19 pandemic may exacerbate this risk. Perfectionistic characteristics are common among physicians and recent work suggests that perfectionism may play a role in physician burnout. The current study aims were to assess the prevalence of burnout among pediatric emergency medicine physicians (PEMP) during the COVID-19 pandemic and examine the effects of demographics and perfectionism on burnout.

Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study.

Fracture reduction under point-of-care ultrasound (POCUS) guidance facilitates measurement of residual angulation or displacement that may not be apparent on examination. Point-of-care ultrasound is without patient or staff exposure to ionizing radiation and enlists no additional staffing resources or patient transfer. We conducted a chart review of all children who underwent reduction of a distal forearm fracture in the pediatric emergency department over a 2-year period, from September 2018 to September 2020. We compared length of stay (LOS) with that for orthopedist-performed distal forearm reductions during the study period. We allowed a 6-week lag period to ensure no missed rereduction before analyzing the data. After reduction, children were instructed to follow up with an orthopedist within 1 week. Children with loss of reduction on orthopedic follow-up are referred back through our emergency department for operative reduction. A total of 74 children with 75 distal forearm fractures were identified. Average LOS was 179 minutes for the pediatric emergency medicine physician reductions and 215 minutes for the orthopedist reductions (P < 0.001). Ninety-six percent of reductions were completed with POCUS assistance, and 61% had less than 5 degrees of angulation on postreduction radiography. Only 2.7% of children underwent rereduction. Distal forearm fracture reductions by a pediatric emergency medicine physician under POCUS guidance have a high rate of excellent alignment, low rate of failed reduction, and significantly shorter LOS (P < 0.001) than reductions performed by orthopedists.

Heat stroke: knowledge and practices of medical professionals in pediatric emergency medicine departments \u2013 a survey study

Background and importanceHeat stroke is a life-threatening condition affecting children worldwide. Rapid cooling remains the most important feature of emergency management. The accepted preferred method of evaporative cooling in the ED as listed by the reference text book endorsed by the Israeli Society of Pediatric Emergency Medicine (PEMI), is actively cooling the patient by spraying him with water and positioning fans to blow air across the body.ObjectiveThis study aimed to assess Israeli health care workers (HCWs) medical professionals’ knowledge and preparedness of treating heat stroke and recommend policy changes to ensure better treatment based on survey results.Design, settings and participantsA cross-sectional survey of all HCWs working in an ED that accepts children was conducted. An online questionnaire was utilized to assess heat stroke management practices and available resources in all Israeli pediatric emergency departments (PEDs).Main resultsData from 208 health care workers was analyzed. Only 30% of the participants reported ever treating a patient with exertional heat stroke. Two scenarios were presented to the participants: motor vehicle-related child hyperthermia (MVRCH) in an infant and an adolescent with exertional heat stroke. One hundred twenty-five (60%) and 83 (40%) participants, respectively, listed cool water with a fan as the primary mode of cooling, which is considered the appropriate preferred method of evaporative cooling in the PED. Certificated pediatric emergency medicine (PEM) physicians answered significantly more correctly regarding both scenarios’ management (P < 0.001). Participants who were trained via simulation in the past, answered significantly more correctly regarding the exertional heat stroke scenario (P < 0.01), however no difference was found regarding the MVRCH case.Conclusions: The present study exposes weaknesses in HCW knowledge, PED resources, and published PED policies for appropriate management of children following heat stroke. Our finding emphasizes the importance of both certificated PEM physicians attendance and simulation performance for implementing proper management of patients with heat stroke. A policy change should be performed among the Israeli PED community, with respect to establishing and implementing guidelines for treatment of exertional heat stroke. A future study, following an interventional simulation program is planned to be performed.

Exploring the Differences in Macrocognition Between Experts and Non-CHD Experts Managing Congenital Heart Disease (CHD)

Background and aims: Children with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute management is often best achieved with the guidance of CHD experts. Access to such expertise may be limited outside specialty heart centers and the fragility of these patients is cause for discomfort among many emergency medicine physicians. An understanding of the differences in macrocognition of these clinicians could shed light on some of the causes of discomfort and facilitate the development of a sociotechnological solution to this problem. Methods: Cardiac intensivists (CHD experts) and pediatric emergency medicine physicians (non-CHD experts) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Klein’s macrocognitive framework and inductively to allow for new or modified characterization of dimensions. Results: While both CHD-experts and non-CHD experts relied on the macrocognitive functions of sensemaking, naturalistic decision making and detecting problems, the specific data and mental models used to understand the patients and course of therapy differed between CHD-experts and non-CHD experts. Conclusion: Characterization of differences between the macrocognitive processes of CHD experts and non-CHD experts can inform development of sociotechnological solutions to augment decision making pertaining to the acute management of pediatric CHD patients.

Maintenance of Certification Pediatrics: Pediatric Emergency Medicine (PEM): The New Part 3 Maintenance of Certification Assessment Option.

Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.

Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future?

* Abbreviation: CAP — : community acquired pneumonia > It’s tough to make predictions, especially about the future. > > Yogi Berra In this issue of Pediatrics , Gao et al1 examine the value of clinical gestalt in predicting the progression to severe disease in children presenting to an urban pediatric emergency department with suspected community acquired pneumonia (CAP). CAP is one of the most common serious infections of childhood, accounting for ∼2 million annual ambulatory visits and 124 000 annual hospitalizations in the United States alone.2–5 Globally, childhood pneumonia accounts for significant morbidity and mortality, particularly in low- and middle-income countries.6 Complications of CAP include pleural effusions, empyema, sepsis, and others that may require additional procedures, ICU stays, and prolonged antibiotic courses. The management of CAP relies on appropriate diagnosis as well as thoughtful risk stratification to inform decisions, such as antimicrobial choice, patient disposition, and follow-up timing. Clinicians are often required to make these types of diagnoses and initial management decisions on the basis of brief encounters with patients. The impressions made on these visits often rely on a heuristic (ie, shortcut) approach to diagnosis and management. Much of medical decision-making relies on pattern recognition, which can include gestalt, gut feeling, or intuition.7 In this prospective cohort study, pediatric emergency medicine physicians were asked to estimate the probability that patients with suspected pneumonia (based on initial patient encounter and chest radiograph findings) will develop a complicated and/or severe pneumonia.1 The authors found that clinician gestalt was most sensitive (>90%) when the estimate for a complicated pneumonia was low and most specific (>90%) when the probability for complications to develop was judged to be … Address correspondence to Louis M. Bell, MD, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. E-mail: belll{at}chop.edu

Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model.

This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk. We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression. We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout. Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.

AAP Publications Reaffirmed or Retired

Policy Statement. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics . 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/135/4/e1097. Reaffirmed September 2019 Technical Report. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics . 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/135/4/e1113. Reaffirmed September 2019 Policy Statement. Consumption of raw or unpasteurized milk and milk products by pregnant women and children. Pediatrics . 2014;133(1):175–179. Available at: https://pediatrics.aappublications.org/content/133/1/175. Reaffirmed November 2019 Policy Statement. Off-label drug use in children. Pediatrics . 2014;133(3):563–567. Available at: https://pediatrics.aappublications.org/content/133/3/563. Reaffirmed November 2020 Technical report. Prevention of … Corresponding author; email: jshaw{at}aap.org

Interpretation of Emergency Department Focused Cardiac Ultrasonography by Pediatric Emergency Medicine Physicians and Pediatric Cardiologists

Interpretation of Emergency Department Focused Cardiac Ultrasonography by Pediatric Emergency Medicine Physicians and Pediatric Cardiologists

Performance of Pediatric Emergency Medicine Faculty After Point-of-Care Ultrasound Credentialing Implementation.

As point-of-care ultrasound (POCUS) continues to evolve, a national standardized curriculum for training and credentialing pediatric emergency medicine (PEM) physicians is still lacking. The goal of this study was to assess PEM faculty in performing and interpreting POCUS during implementation of a training curriculum. Sixteen full-time PEM faculty with either limited or no prior POCUS experience were trained to perform 4 ultrasound studies. Twelve of the 16 completed the training with a goal of credentialing within 12 months of implementation. For each faculty, we assessed competency by comparing precurriculum and postcurriculum test assessments and by evaluating quality of POCUS acquisition and accuracy of interpretation. We also monitored the amount of continuing medical education (CME) hours completed to ensure a minimum didactic component. We found a significant improvement in POCUS competency comparing precurriculum to postcurriculum test assessments (55.4% vs 75.6%, P < 0.0002). One thousand two hundred seventy images were submitted over the course of the curriculum. Accuracy, sensitivity, and specificity were 98.23% (confidence interval [CI] = 97.18-98.97), 97.01% (CI = 92.53-99.81), and 98.43% (CI = 97.33-99.81), respectively. Faculty self-rating of image quality was significantly higher than expert reviewer rating of image quality (3.4 ± 0.86 vs 3.2 ± 0.56, P < 0.0001). We found no change in expert reviewer rating of image quality over time. Faculty completed a combined 232.5 CME hours (average, 17.4 ± 10.8), with the majority of hours coming from an institutional POCUS CME workshop. These results show that a structured curriculum can improve PEM faculty POCUS competency.

AAP Publications Reaffirmed or Retired

Policy Statement. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics. 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/135/4/e1097. Reaffirmed September 2019Technical Report. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics. 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/135/4/e1113. Reaffirmed September 2019Policy Statement. Consumption of raw or unpasteurized milk and milk products by pregnant women and children. Pediatrics. 2014;133(1):175–179. Available at: https://pediatrics.aappublications.org/content/133/1/175. Reaffirmed November 2019Policy Statement. Off-label drug use in children. Pediatrics. 2014;133(3):563–567. Available at: https://pediatrics.aappublications.org/content/133/3/563. Reaffirmed November 2020Technical report. Prevention of drowning. Pediatrics. 2010;126(1):e253–e262. Available at: https://pediatrics.aappublications.org/content/126/1/e253. Reaffirmed February 2019Clinical report. Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics. 2015;135(3):566–574. Available at: https://pediatrics.aappublications.org/content/135/3/566. Reaffirmed October 2020Clinical report. Management of food allergy in the school setting. Pediatrics. 2010;126(6):1232–1239. Available at: https://pediatrics.aappublications.org/content/126/6/1232. Reaffirmed October 2020Policy statement. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008;122(5):1127–1134. Available at: https://pediatrics.aappublications.org/content/122/5/1127. Reaffirmed October 2020Clinical report. Suicide and suicide attempts in adolescents. Pediatrics. 2016;138(1):e20161420. Available at: https://pediatrics.aappublications.org/content/138/1/e20161420. Reaffirmed October 2020Technical report. SIDS and other sleep‐related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):e1341–e1367. Available at: http://pediatrics.aappublications.org/content/128/5/e1341. Reaffirmed October 2020Policy statement. SIDS and other sleep‐related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030–1039. Available at: http://pediatrics.aappublications.org/content/128/5/1030. Reaffirmed October 2020Policy statement. Pediatrician-family-patient relationships: managing the boundaries. Pediatrics. 2009;124(6):1685–1688. Available at: https://pediatrics.aappublications.org/content/124/6/1685. Reaffirmed October 2020Clinical report: Attention-deficit/hyperactivity disorder and substance abuse. Pediatrics. 2014;134(1):e293–e301. Available at: https://pediatrics.aappublications.org/content/134/1/e293.full. Reaffirmed October 2020Clinical report: Health supervision for children with sickle cell disease. Pediatrics. 2002;109(3):526–535. Available at: https://pediatrics.aappublications.org/content/109/3/526. Reaffirmed September 2020Policy statement. Postnatal corticosteroids to prevent or treat chronic lung disease following preterm birth Pediatrics. 2010;126(4):800–808. Available at: https://pediatrics.aappublications.org/content/126/4/800. Reaffirmed September 2020Policy statement. Children’s Health Insurance Program (CHIP): accomplishments, challenges, and policy recommendations. Pediatrics. 2013;133(3):e784–e793. Available at: https://pediatrics.aappublications.org/content/133/3/e784. Reaffirmed August 2020Policy statement. Guiding principles for pediatric hospital medicine programs. Pediatrics. 2013;132(4):782–786. Available at: https://pediatrics.aappublications.org/content/132/4/782. Retired August 2020

Experiences of underrepresented faculty in pediatric emergency medicine.

The aim of this study is to elucidate the unique challenges faced by pediatric emergency medicine (PEM) physicians from racial/ethnic groups underrepresented in medicine (URiM). This study is a subanalysis of data from 18 URiM faculty from a sample of 51 semistructured key informant interviews with PEM faculty in the top NIH-funded pediatric departments and highest-volume pediatric EDs in the country. Faculty are from eight hospitals representing a spectrum of geographic locations including the northeastern, midwestern, western, and southern regions of the country. Of 18 study participants, the majority were Black (72.2%) and female (83.3%). Three main thematic categories were identified: challenges related to race, support systems, and suggested strategies to improve diversity and inclusion in PEM. A common race-related experience was microaggressions from colleagues and patients. Additionally, when attempting to lead and assert themselves, URiM women in particular were perceived as "angry" and "intimidating" in a way that non-URiM peers were not. As a result of these negative experiences, participants described the need to go above and beyond to prove themselves. Such pressure produced stress and feelings of isolation. Participants combatted these stressors through resilience strategies such as formal mentorship and peer and family support. Participants indicated the need to increase diversity and create more inclusive work environments, which would benefit both URiM physician wellness and the diverse patients they serve. Those URiM in PEM face subtle racial discrimination at an institutional, peer, and patient level. The stress caused by this discrimination may further contribute to physician burnout in PEM. While URiMs adopt individual resilience strategies, their unique challenges suggest the need for departmental and institutional efforts to promote greater diversity and inclusion for physician wellness, retention, and quality patient care.

Reflections on three multi-cultural experiences

As a Pediatric Emergency Medicine physician, I rarely, if ever think about diversity in the patient population I treat. I am task driven and put together the pieces of the puzzle to understand the ...

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians.

Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed. One hundred patients were enrolled; median patient age was 24months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ=0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72). POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.

Coronavirus-19 Multisystem Inflammatory Syndrome in Children (MIS-C): A Pediatric Simulation Case for Residents, Fellows, and Advanced Practice Providers.

IntroductionA rare but serious condition often requiring intensive care, multisystem inflammatory syndrome in children (MIS-C) is characterized by hyperinflammatory shock related to the SARS-CoV-2 pandemic. This resource teaches residents, pediatric emergency medicine fellows, and advanced practice providers who care for children to recognize and manage MIS-C and associated sequelae while applying the basic principles of pediatric resuscitation.MethodsThe simulation case was based on a real patient who presented to the emergency department with fever, rash, and cardiogenic shock. We designed the scenario to be used with a high-fidelity school-age mannequin in an emergency center resuscitation room or simulation lab. The case took 25 minutes to run, followed by a 15- to 20-minute debrief session. Personnel required for the case included a simulation technician, case instructor, emergency department nurse, parent, and consultant. Learners had to recognize the syndrome and treat the resultant shock and arrhythmia with a combination of vasopressors, antiarrhythmics, and defibrillation. Afterward, learners participated in a formal debriefing session and completed a written evaluation.ResultsTwenty-five learners (six pediatric emergency medicine fellows, 12 residents, and seven advanced practice providers) participated in the scenario over a 3-month period. The written evaluation was completed by 20 of the 25 participants; all 20 felt their confidence, comfort, and knowledge regarding the topic had increased, with an average score of 5 (strongly agree) on a 5-point Likert scale.DiscussionThis simulation case offers an effective experience for learners to become comfortable and confident in recognizing and managing MIS-C.

A standardized definition of near-fatal child maltreatment: Results of a multidisciplinary Delphi process

BackgroundThe 2016 Presidential Commission to Eliminate Child Abuse and Neglect Fatalities identified systematic review of all cases of near-fatal child maltreatment as a necessary step towards prevention of child maltreatment fatalities. A critical barrier to adoption of this recommendation is the lack of a standard definition of “near-fatality” in the context of suspected child maltreatment. ObjectiveTo develop a consensus definition of near-fatal child maltreatment to be used in practice, policy, and research. Participants and SettingA multidisciplinary expert panel of 23 individuals from across the U.S. including child abuse pediatricians, pediatric intensivists, pediatric emergency medicine physicians, child welfare administrators, child welfare researchers, and child injury/fatality researchers. MethodsA modified Delphi process reflecting an iterative process of 3 rounds of surveys of expert opinion, statistical summary of survey response, and feedback of summary statistics. Consensus was defined as 75 % of panelists ranking an element as required (≥80 on a scale of 0–100) to meet a definition of near-fatality (75th% threshold). ResultsExperts defined near-fatal child maltreatment as life-threatening cardiopulmonary dysfunction directly attributable to suspected abuse or neglect as evidenced by (a) respiratory insufficiency/failure requiring intubation and mechanical ventilation, (b) respiratory insufficiency/failure requiring medications to reverse effects of toxic ingestion, or (c) cardiac arrhythmia with/without cardiopulmonary resuscitation (CPR). ConclusionsA consensus definition of near-fatal child maltreatment should be introduced in child protective services processes and in child fatality/near-fatality reviews to improve our ability to identify, review, and respond to trends in near-fatal child maltreatment at local, regional, and national levels.

Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department.

We sought to describe the test characteristics of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians after structured cardiac POCUS training. We evaluated the use of clinically indicated cardiac POCUS by PEM physicians in a single tertiary care pediatric emergency department after implementation of a focused cardiac POCUS training curriculum. The test characteristics of the sonologist interpretation were compared with expert POCUS review, by PEM physicians who have completed PEM POCUS fellowship training, for the assessment of both pericardial effusion and left ventricular systolic dysfunction. A total of 1241 cardiac POCUS examinations were performed between July 2015 and December 2017, of which 456 were clinically indicated and underwent expert POCUS review and comprised the study sample. These examinations were performed by 33 different PEM attending sonologists. Chest pain (52%), dyspnea (20%), and tachycardia (18%) were the most common indications for cardiac POCUS. Prevalence of pericardial effusion and global systolic dysfunction based on expert POCUS review were 11% (48/443) and 4% (16/435), respectively. Real-time cardiac POCUS interpretation had a sensitivity and specificity of 100% and 99.5%, respectively, for both pericardial effusion and left ventricular systolic dysfunction when compared with expert POCUS review. Cardiac POCUS is both sensitive and specific for identifying pericardial effusion and left ventricular systolic dysfunction when performed by PEM attendings with focused training.

Evaluating a Web-based Point-of-care Ultrasound Curriculum for the Diagnosis of Intussusception.

Intussusception is a pediatric medical emergency that can be difficult to diagnose. Radiology-performed ultrasound is the diagnostic study of choice but may lead to delays due to lack of availability. Point-of-care ultrasound for intussusception (POCUS-I) studies have shown excellent accuracy and reduced lengths of stay, but there are limited POCUS-I training materials for pediatric emergency medicine (PEM) providers. We performed a prospective cohort study assessing PEM physicians undergoing a primarily Web-based POCUS-I curriculum. We developed the POCUS-I curriculum using Kern's six-step model. The curriculum included a Web-based module and a brief, hands-on practice that was developed with a board-certified pediatric radiologist. POCUS-I technical skill, knowledge, and confidence were determined by a direct observation checklist, multiple-choice test, and a self-reported Likert-scale survey, respectively. We assessed participants immediately pre- and postcourse as well as 3months later to assess for retention of skill, knowledge, and confidence. A total of 17 of 17 eligible PEM physicians at a single institution participated in the study. For the direct observation skills test, participants scored well after the course with a median (interquartile range [IQR]) score of 20 of 22 (20-21) and maintained high scores even after 3months (20 [20-21]). On the written knowledge test, there was significant improvement from 57.4% (95% CI= 49.8 to 65.2) to 75.3% (95% CI= 68.1 to 81.6; p<0.001) and this improvement was maintained at 3months at 81.2% (95% CI= 74.5 to 86.8). Physicians also demonstrated improved confidence with POCUS-I after exposure to the curriculum, with 5.9% reporting somewhat or very confident prior to the course to 76.5% both after the course and after 3months (p<0.001). After a primarily Web-based curriculum for POCUS-I, PEM physicians performed well in technical skill in POCUS-I and showed improvement in knowledge and confidence, all of which were maintained over 3 months.

Improving Emergency Care for Children With Medical Complexity: Parent and Physicians' Perspectives.

Children with medical complexity (CMC) have high rates of emergency department (ED) utilization, but little evidence exists on the perceptions of parents and pediatric emergency medicine (PEM) physicians about emergency care. We sought to explore parent and PEM physicians' perspectives about 1) ED care for CMC, and 2) how emergency care can be improved. We performed semistructured interviews with parents and PEM physicians at a single academic, children's hospital. English-speaking parents were selected utilizing a standard definition of CMC during an ED visit in which their child was admitted to the hospital. All PEM physicians were eligible. We developed separate interview guides utilizing open-ended questions. The trained study team developed and modified a coding tree through an iterative process, double-coded transcripts, monitored inter-rater reliability to ensure adherence, and performed thematic analysis. Twenty interviews of parents of CMC and 16 of PEM physicians were necessary for saturation. Parents identified specific challenges related to ED care of their children involving time, information gathering, logistics/convenience, and multifaceted communication between health teams and parents. PEM physicians identified time, data accessibility and availability, and communication as inter-related challenges in caring for CMC in the ED. Suggestions reflected potential solutions to the challenges identified. Time, data, and communication challenges were the main focus for both parents and PEM physicians, and suggestions mirrored these challenges. Further research and quality improvement efforts to better characterize and mitigate the identified challenges could be of value for this vulnerable population.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied. This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians. Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment. A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure. Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.