M O N T H L Y N E W S L E T T E R F R O M T H E D E P A R T M E N T O F P E D I A T R I C E M E R G E N C Y M E D I C I N E

PEM

PEDIATRIC PREPAREDNESSSimulation-based training programs to prepare physicians

V O L U M E 1 • I S S U E   7   •   J A N U A R Y   2 0 1 8

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Pediatric Preparedness

Events and Updates

Recent presentations

Study updates

Volunteer of the Month

Contacts

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02References: Katznelson, Jessica H., et al. “Improving Pediatric Preparedness in Critical Access Hospital Emergency Departments.” Pediatric Emergency Care, vol. 34, no. 1, 2018, pp. 17–20., doi:10.1097/pec.0000000000001366.

While McMaster Children’s Hospital is fortunate in having an ED dedicated to the pediatric population, with house staff trained in pediatric emergency medicine – this is not the case in rural areas.  Rural areas may not have the resources, whether work force or finances, to support emergency services, let alone pediatric emergency services for their respective communities.  This dire need can be further exacerbated by travel time needed to reach a tertiary centre that can provide adequate care.  So, what can be done to provide access, education, and services to prepare physicians who work in rural environments and to improve pediatric health outcomes?

The journal of Pediatric Emergency Care published an article (https://goo.gl/ivVgrt)  to assess if a simulation program in Critical Access Hospitals (CAH) can prepare physicians for pediatric emergencies.  CAH are institutions in the US which rarely have pediatric emergencies and/or physicians trained to manage pediatric emergencies.  They are located more than 35 miles (~56 km) from the nearest hospital.  Simulations have shown to improve team performance, increase confidence in one’s ability and provide exposure to situations that aren’t typically encountered.

The study utilized an in-situ 12-month pediatric simulation program at 5 CAHs.  A 35-item checklist inquiring about resuscitation methods was used to evaluation team performance.  Checklist items included: identification of team leader, airway opening, appropriate CPR, focused history, appropriate fluid resuscitation, debriefing, amongst others.  The 6 scenarios included: Airway Obstruction (croup), Respiratory Distress (asthma), Shock (cardiogenic), Cardiac Arrest, Status Epilepticus and Altered Mental Status (Diabetic Ketoacidosis).  The Kruskal-Wallis rank test was used to assess for differences in average scores among the CAH institutions.  

The results of the test showed no difference in average scores among institutions (p = 0.90). The scores also showed a significant downward trend over time, with a scenario-to-scenario decrease (p < 0.01).  In other words, checklist scores improved over time both within and across Institutions (more “yes” answers to successfully completed recommended interventions). All of the providers surveyed in the last month stated they would benefit from ongoing scenarios.  Four of the 5 participating CAHs have continued to run regularly scheduled pediatric simulations in the year after completion of the study, with the fifth hospital in the process of restarting.

While the study was limited to only 5 CAHs in North Carolina and simulations were limited to ages 2-6 years, it did show that simulations (and maintenance of them) can be beneficial in training physicians.  At McMaster, a study is underway to assess pediatric emergency preparedness in the Canadian context.  A national survey has been mailed out to family physicians and pediatricians to assess preparedness in an office-based setting.  The survey seeks to find out if: physicians are aware of CPS guidelines, have essential first aid training, have adequate supplies in their office, amongst others.  In either case, what is important is that access to education and resources are vital in the management of urgent pediatric cases.                                                                                                                                                                          - Dr. April Kam (kama@mcmaster.ca)

Preparing for Pediatric Emergencies

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Events & UpdatesPediatric Emergency Research

Canada (PERC) 2018Delegates from all Canadian medical institutions were present at Mt. Tremblant from January 28th to February 1st, 2018.  The Pediatric Emergency Research Canada (otherwise known as PERC) is a "well-established network of health care researchers at 15 Canadian Children’s Hospitals that is dedicated to improving care in pediatric emergency medicine through multi-centre research. PERC has a track recording of producing results that matter."

Guest speakers included:        1) Dr. PJ Subbarao - The CHILD study - a multicenter Canadian birth cohort study        2) Dr. Rich Ruddy - Network and single center research - 'New' models to consider

Representing McMaster at PERC included: Dr. Anthony Crocco, Dr. Mohamed Eltorki, Dr. April Kam, Dr. Jeffrey Pernica, Dr. Melissa Parker and Mohammed Hassan-Ali.  Study updates and progress reports from SAFER and SQUEEZE trials were presented at the conference.

Several interesting research topics/studies were presented at this year's conference, many of which, will involve McMaster PEM in the upcoming years:        1) INK - intranasal ketamine for fracture reduction        2) Family Needs survey        3) PRIMED - biomarkers for appendicitis        4) Cross sectional assessment of PEM MH management and outcome

Next year's conference will be held in Banff, Alberta.  For more information, visit: https://perc-canada.ca/

Events & Updates

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D e p a r t m e n t o f P e d i a t r i c s C h i l d H e a l t h R e s e a r c h D a y 2 0 1 8

Join us for the 10th annual Child Health Research Day on Wednesday, March 28th, as we celebrate the

contributions to child health research by undergraduate students, medical students, graduate

students, pediatric residents, post-doctoral and clinical fellows, new Faculty and research staff working

in Pediatrics!

Abstracts are now being accepted via the form below; the deadline for submission is February 26,

2018.

C l i c k h e r e f o r m o r e i n f o r m a t i o n a n d o n l i n e r e g i s t r a t i o n

C I H R P R O J E C T G R A N T C O M P E T I T I O N - S P R I N G 2 0 1 8

Pediatrics Internal Deadline: February 16

HRS Internal Deadline: February 26 by 4 pm

CIHR Application Deadline: March 6 by 4 pm

Internal Review timelines for the Spring 2018 Project Grant competition are now available for both HRS

and the Department of Pediatrics. Full information for this funding opportunity is available on the CIHR

website.  

Please let Lindsay Akrong know if you plan to apply

H H S H I G H S C H O O L H E A L T H R E S E A R C H   B U R S A R Y Deadline for mentor applications: March 30, 2018

In its 15th year, this program links mentors with skilled summer students (screened and funded by

HHS) to work on research projects.  For the students, this is an amazing opportunity to gain "hands-

on" experience to further enhance skill sets and gain valuable insight of career choices that will help

them with selecting post-secondary studies. Mentors benefit from having these very capable and

bright young adults joing their programs from July 3, 2018 to August 17, 2018. 

C l i c k h e r e f o r m o r e i n f o r m a t i o n

Events & Updates

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F A C U L T Y O F H E A L T H S C I E N C E S E D U C A T I O N I N N O V A T I O N F U N D

Purpose  To encourage and provide support for the development and evaluation of novel and innovative approaches to health sciences

education in the Faculty of Health Sciences.

Eligibility  All members of the faculty of FHS are eligible for funding support.  Funding cannot be used to supplement another partly

funded project.  All those awarded funding must be willing to present their research at the Geoffrey R Norman FHS Education Research

Day in June.  Priority will be given to projects that address competency-based education, simulation-based education and innovative

pedagogy and projects where theory is used/developed to inform practice.  The activity of the project should be focused on McMaster

Faculty of Health Sciences.

Application Process  Applicants are required to submit:  

1) An abridged CV (max. 3 pages, focussing on previous research and educational scholarship)

2) A project summary - 3 pages maximum, single spaced, plus references, outlining:-

a. Proposed study question/objectives

b. Proposed method of analysis

c. Expected project outcome

d. Strategy for disseminating outcome findings

e. Potential education impact of the study

f. Potential of the research for commercialization, if applicable

3) Budget The following expenses are ineligible:-

a. Salary support for P.I. or other faculty members

b. Computers and other equipment unless integral to the study e.g. voice recording equipment

c. Infrastructure expenses that are presently supported elsewhere (e.g. telephone, administrative assistant)

No university overhead will be charged.  Open Access journal publications costs will be allowed.

4) Adjudication

The adjudication process will be administered by the office of the Associate Dean, Health Professional Education who will chair a

selection committee of senior faculty.  Preference will be given to projects that address the priority areas identified in the Eligibility

section above and that incorporate a design that uses theory to inform practice or uses practice to develop theory.

Award Amount Funding will be awarded to one or more applicants annually for up to two years of funding support to a maximum of

$50,000 per project, spread over the two years; funding for the second year is contingent on the submission of a satisfactory interim

report to the selection committee prior to the end of the first year of funding.  A final report shall be submitted upon completion of the

project.  The selection committee reserves the right to not fund any projects in any given year. Award winners will be announced at the

Geoffrey R. Norman FHS Education Research Day on June 6, 2018.

Application Details

1) Deadline for application April 13, 2018 at midnight.

2) Submit as 1 pdf document with the P.I.’s name and a short version of the title as the document’s name.

3) Submit to the office of the Associate Dean, Health Professional Education c/o mcarthj@mcmaster.ca.

Recent Presentations

H A V E A R E C E N T P U B L I C A T I O N / P R E S E N T A T I O N T H A T Y O U W A N T T O S H O W C A S E H E R E ? S E E C O N T A C T S S E C T I O N T O S U B M I T .

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D r . Q u a n g N g o

D r .   F a h a d M a s u d

Poster title:  Rapid Cycle Deliberate Design in Optimizing Clinical Spaces

Poster presented at: International Meeting for Simulation in Healthcare (IMSH 2018) in Los Angeles, Jan. 13-17, 2018.

Introduction/Background: In situ simulation has been used as a tool for the assessment of clinical spaces.  In a

pediatric tertiary care center, the use of in situ simulation was central in the design of the emergency tracheostomy care

setup in a newly designed complex care ward. A key challenge in this project revolved around how to most efficiently

identify patient safety and design issues, incorporate feedback and evaluate resulting changes. The concept of “rapid

cycle deliberate practice” (RCDP) has been proposed as an educational framework by Hunt et al wherein masterly

learning is achieved through cycles of deliberate practice and real time directed feedback with an expert.  We proposed

the use of RCDP as a framework for quality improvement and clinical space evaluation wherein identified issues in

patient safety and design could be quickly identified, environments modified and changes evaluated all within a short

period of time. 

Methods: In preparation for the cycles, an inter-professional group of key stakeholders met to design the “ideal” first

iteration of the patient care room with respect to tracheostomy care.  Three common emergency tracheostomy care

scenarios (accidental de-cannulation, obstruction and difficult tracheostomy change) were then developed to identify

patient safety and design issues and test subsequent changes. 2 consecutive sessions were then organized in situ using

the above 3 scenarios during regular working hours.  Participants included front line health care staff as well as parents.

 During each simulation, a team of observers recorded feedback using a tool designed for the exercise. Debriefing of the

scenario was done using a “plus/delta” approach and focussed specifically on systems issues. The clinical space was then

 adjusted accordingly and the subsequent scenario run to test the incorporated changes. Validation of the new changes

would be measured as decreasing numbers of changes in subsequent simulations.

Results: Over 5 simulations, issues were recorded using the observer tool into 4 categories: Structure, Workflow, Patient

Safety, and Education. Overall, 41 issues were identified throughout the scenarios with 13 classified as impacting patient

safety requiring immediate correction.  Through the scenarios, 19 changes were made, with each subsequent scenario

having a decrease in both the number of issues identified, and number of changes required.  Controlling for

infrastructure related issues, 0 issues were identified by the 5th simulation.  Video analysis revealed a decrease in time

(seconds) to first responder, first suction, locating bag mask, locating fitted mask, and total time searching for equipment

with each implemented change and subsequent simulation session.

Conclusion: We have adapted an RCDP framework to efficiently achieve the ideal setup for emergency tracheostomy

care in our patient care environment.  Using this method, we were able to effectively identify design and patient safety

issues and implement changes that solved them in a timely fashion.  Traditional quality improvement methods would be

more difficult to implement given the high stakes but low frequency of pediatric emergencies.  To our knowledge, the use

of in situ simulation used in this manner has not been reported before, and could be scaled and adapted to many

different clinical environments dealing with the same types of events. We conclude that RCDP simulation can be applied

to space design and quality improvement in an efficient and cost effective manner.  

Research so far...Video AOM

MISSED (in January)

ENROLLED (in January)

84 14PATIENTS

ENROLLED

TOTAL

62Between 6 - 59 months of age

Primary diagnosis of non-severe AOM

Eligible for watchful waiting prior to filling

antibiotic prescription

PAGE #4545 if your patient:

NEW AOM TRACKING FORM!Please fill out the PINK REFUSAL TO

PARTICIPATE form in Acute or Ambulatory

Required information includes: Patient label,

Physician name and date, and CHECKMARK if

if the patient is INELIGIBLE, REFUSED or

MISSED

WE NOW HAVEWEEKEND RESEARCH

SUPPORT!

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TOTAL

78

45MISSED

(in January)ENROLLED (in January)

3PATIENTS

ENROLLED

SAFER

PAGE #4545 if your patient:Between 6 months - 10 years presenting with CAP:

Fever (>37.5 C axillary, >37.7 C oral, >38 rectal) recorded

in ED or home in the 48h prior to presentation

Any one of: tachypnea on exam, cough on exam/history,

increased work of breathing on exam, auscultatory

findings consistent with pneumonia

Infiltrates on CXR consistent with bacterial CAP as judged

by ED physician

Attending ED physician diagnoses the child with primary

CAP

Please fill out the MANILA REFUSAL TO

PARTICIPATE form in Acute or Ambulatory

Required information includes: Patient label,

Physician name and date, and CHECKMARK if if

the patient is INELIGIBLE, REFUSED or MISSED

NEW SAFER TRACKING FORM!WE NOW HAVE WEEKEND RESEARCH

SUPPORT!

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09

Eligible patient?

No

Track

Yes

Ask patient:

"Would they

like to hear

about study?"

No

Yes

RA Available?

No

Consent to

Approach?

Page #4545 &

Give RX to

study team

RA will notify MD if

patient enrolled or not

No

Yes

Give patient

caregiver

package &

label green

tracking form

Refer to the flowchart below, to ensure that all eligible patients can be

recruited in a smooth fashion.  Please see Research Assistants or PEMMREP Volunteers for assistance.

SAFERVideo AOM

Eligible patient?

No

Track

Yes

Ask patient:

"Would they

like to hear

about study?"

No

Yes

RA Available? No

Page #4545 or notify

volunteer & Give RX

to patient

RA will notify MD if

patient enrolled or not

Track

Research so far...QAPPE

230TOTAL

Primary objectives are: Decreasing

unnecessary appendectomies (negative

appendectomies), Decreasing unnecessary

abdominal U/S and or CT scans, Decreasing

unnecessary hospital admissions for serial

examinations

Secondary objective is: Acting as a guide for

other centers in resource allocation and

referral patterns

Population: Pediatric patients (0-18 years)

presenting to the ED at MCH with abdominal

pain and suspected appendicitis

PATIENTS ENROLLED

ENROLLED (in January)

10

SQUEEZE

PAGE #4552 if your patient:*On-call hours: 4:30 pm to 8:30 AM, please dial

x76443 to request page. Do not use 87* to send

page during on-call hours. If SQUEEZE Trial

pager unavailable page

Dr. Melissa Parker #2073TOTAL

73PATIENTS

ENROLLED

2ENROLLED (in January)

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Dr. Parker and the SQUEEZE team would like to thank all the PEM Physicians, Nurses

and Learners for their continued support in

screening for eligible study patients!

Volunteer of the Month

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Lindsay LaBrash

For the month of January, PEMMREP and the AOM/SAFER study

teams would like to honour Lindsay as the Volunteer of the Month!

Lindsay joined the PEMMREP program in September 2017.  From

the get-go, we knew Lindsay would excel in this program.  Lindsay

has been diligent and consistent throughout her volunteer

activities.

She can independently recruit for AOM studies and also has been

involved in additional studies such as Emergency Preparedness and

Febrile Neutropenia.

In addition to being a Life Sciences student, she is active in child

and maternal heath by working at a fertility clinic.

Currently, Lindsay is in her final year and hopes to pursue a

Masters.  

Thank you Lindsay, for your continued support!

Have something to say in the next newsletter?Mohammed Hassan-Ali, MD, MSc Clinical Research Coordinator Division of Emergency Medicine Department of Pediatrics MUMC 2R107 hassam5@mcmaster.ca 905-521-2100 x 73864

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