A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Objective: We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States. Methods: We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network. Results: We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%). Conclusions: This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics

National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic

Background: The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections. Aim: To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide. Methods: A cross-sectional multi-center national survey of PICU medical director(s) from children's hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation. Results: We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children's hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives. Conclusions: A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves

Balancing clinical team perceptions of the workplace : applying 'work domain analysis' to pediatric cardiac care

The safety, reliability, and stability of the pediatric cardiology workplace are continuously challenged. Known factors include the complexity of patient care, keeping up to date with evidence based practice, harnessing the implications of innovations in technology, and adapting to changes in the structure of health services and facilities. The differences between individual clinical team perspectives and impressions formed by other teams across the organization produce divergent perspectives on clinical work. This paper makes a case for investing in a social science framework entitled 'work domain analysis' to better understand how health teams function reliably within the wider healthcare organization. Work domain analysis was developed to equip people in complex work environments with the skills and awareness to identify and adjust the margins for safety in normal work by making the boundaries between management imperatives, workload and safety (in this case, pediatric cardiac care) more apparent to a wider range of people. Healthcare can no longer afford to be precious about methods adopted from other industries due to the high complexity of the clinical workplace. The paper outlines an approach to work domain analysis that can greatly enhance the engagement and awareness of clinicians. The opportunities for practical applications of work domain analysis to pediatric care are discussed

How not to run an incident investigation

Incident investigation is an integral feature of perioperative surgical safety programs and is likely to be fundamental in directing future initiatives. Advances in clinical practice and biomedical technology make the challenge of doing effective incident investigation more complex and nuanced. There is a palpable distance between the stable incident investigation activities of quality and safety departments and the continually evolving scope of surgical practice necessitating increasingly risky and complex procedures, requiring clear communication across clinical disciplines, and ongoing adjustment to the subtle changes in workplace conditions. Incident investigation should not be a remote activity of senior management disconnected from everyday practice in the perioperative setting but a functional tool for discovering fresh insights about the challenging aspects of the local clinical workplace in context. Local experience and expertise are important factors in shaping a culture of good clinical judgment and decision-making. However, clinicians remain ambivalent about incident investigation processes and tend to find more value in the informal debriefing conversations that start up after an adverse event across the organization. Perhaps the establishment of local review meetings and departmental debriefings is the most vital aspect of any incident investigation process. A good and timely debrief shifts the conversation from a retrospective search for isolated causes to a prospective exploration of patterns and cues in the local clinical workplace that emerge from everyday activity over time. Nonetheless, it is commonplace for hospitals and health service providers to use structured methods for the analysis of adverse events, the determination of contributing factors, and the implementation of corrective actions to improve the safety and performance of clinical systems (e.g., root cause analysis in combination with human factors engineering). Incident investigation typically involves a broad range of techniques for gathering and arranging the facts that relate to adverse events into a report that categorizes areas of breakdown and vulnerability in the interactions within a clinical micro-system. Investigation methods have become systematized and organized over time around a predetermined set of procedures to produce the required data. However, it does not follow that incidents need to be investigated according to a fixed scheme. Above all, clinicians need to have the authority and inclination to shape the investigation process to achieve the ends that they most value in their particular workplace

Making sense of root cause analysis investigations of surgery-related adverse events

This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes

Does Lowering Heart Rate Improve Outcomes in Children With Dilated Cardiomyopathy and Chronic Heart Failure?

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