Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program

Abstract

Objectives: The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulationbased collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.Methods: This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores.Results: A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline.Conclusions: This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study

“…Several state initiatives led by pediatric academic medical centers have utilized simulation to improve pediatric readiness and quality of care in general EDs measured in simulated settings for high acuity conditions. 12,13,15,16 Our findings mirror other national, statewide, and local initiatives that have improved the day-to-day pediatric readiness and promoted the quality of care provided in general EDs.…”

“…6 Significant associations between WPRS, mortality rate, and the length of stay in both the hospital and intensive care unit setting have also been reported. 7 Multiple studies have also noted that general EDs with lower WPRS are less likely to adhere to best practice guidelines in a simulated environment for high acuity conditions 8 including sepsis, 9 seizure, 10 cardiac arrest, 11 diabetic ketoacidosis, 12 and respiratory failure. 13 To address this variability, several US states and national organizations have implemented programs to improve pediatric readiness including the National Pediatric Readiness Project (NPRP).…”

Quality of Resuscitative Care Provided to an Infant With Abusive Head Trauma in Community Emergency Departments

“…These finding are consistent with a previous study showing improved quality of resuscitative care in CEDs that are more proximal to the AMC, and this could be explained by the fact that more proximal CEDs have more frequent interaction with the pediatric trauma center and easier access to pediatric specialists and resources. 36 Our simulation-based initiative was well received by CEDs providers. Ninety-nine of participating providers reported increased comfort in the recognition of AHT.…”

Implementation of a pediatric in situ, train‐the‐trainer simulation program in general emergency departments

“…3,7 In this model, health care professionals are removed from clinical responsibilities to participate in simulations followed by debriefing. 8,9 This model has shown efficacy 3,7,[10][11][12] ; however, these simulations do not present real-world clinical challenges of taking care of multiple patients simultaneously while on shift. Another ISS model included distributing simulation kits and video links to train community health care professionals.…”