Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy leading to hemolysis, increased endothelial adhesion, inflammation, and vasculopathy. While most children with SCD have normal pulmonary function, lung capacity and expiratory flows are lower compared to age- and racially matched controls. Airway obstruction dominates in children, with restrictive ventilatory defects becoming more prevalent in adolescents and young adults. Decreased pulmonary function, physician-diagnosed asthma, airway hyperresponsiveness, wheezing, and sleep-disordered breathing are associated with more frequent episodes of acute chest syndrome and vaso-occlusive crisis. Chronic lung disease, thromboembolism, hypoxemia, and sleep-disordered breathing are associated with the development of pulmonary hypertension and ventricular dysfunction which carry significant morbidity and mortality risk in adults. Most treatments for cardiopulmonary complications of SCD are based on guidelines developed for the general population. Although most guidelines do not recommend routine screening of asymptomatic children, patients with cardiopulmonary symptoms should be monitored and treated by subspecialists in a multidisciplinary setting. Disease modifying treatments such as hydroxyurea are attenuating some of the cardiopulmonary complications in SCD. More studies need to be done to assess the effects of newer disease modifying treatments targeting hemolysis and decreasing endothelial adhesion.

OBJECTIVE:Although positive airway pressure (PAP) is effective for treating obstructive sleep apnea (OSA) in infants, there is a lack of data on caregivers' experiences administering PAP at home. Understanding caregivers' perspectives may change health care professionals approach to PAP initiation. Our study aimed to gain comprehensive insight into caregivers' beliefs, perceptions, and challenges associated with implementing PAP for infants with OSA, considering the transition from inpatient hospitalization to home. METHODS:In this single-center prospective longitudinal study, caregivers of infants with OSA less than 12 months old who were initiated PAP during inpatient hospitalization underwent two semi-structured interviews over 3 months. The interview data were analyzed using directed content analysis, utilizing the health belief and socioecological models as theoretical frameworks. Data were coded and clustered into themes that reflected the evolving perspectives and experiences of caregivers. RESULTS:Eight caregivers completed semi-structured interviews, revealing three key themes. First, despite initial negative attitudes towards the equipment, caregivers recognized PAP benefits and through self-efficacy and cues to action, were motivated to use PAP at home. Second, caregivers encountered various barriers to adherence; however, caregivers' self-efficacy improved with time and practice. Lastly, interpersonal, organizational, and community support enhanced adherence while lack thereof hindered implementation. CONCLUSION:Caregivers of infants with OSA understand the importance of PAP therapy. Providing family-centered care and targeted interventions helps caregivers maintain adherence to PAP for infants. By understanding the lived experiences of caregivers, health care professionals can better meet the needs of families and optimize the effectiveness of PAP.

Childhood interstitial lung disease (chILD) is a heterogeneous group of diffuse lung diseases that can be challenging to diagnose. With relative rarity of individual entities, data are limited on disease prevalence, care patterns, and healthcare utilization. The objective of this study was to evaluate chILD prevalence and review diagnostic and clinical care patterns at our center. A single-center, retrospective cohort study was conducted of patients receiving care at the Children's Hospital of Philadelphia (CHOP) between 1 January 2019 and 31 December 2021. Through query of selected ICD-10 billing codes relevant for chILD and medical chart review, a total of 306 patients were identified receiving pulmonary care during this period. Respiratory symptom onset was documented to have developed before 2 years of age for 40% of cases. The most common diagnostic categories included those with oncologic disease (21.2%), bronchiolitis obliterans (10.1%), and connective tissue disease (9.5%). Genetic testing was performed in 49% of cases, while 36% underwent lung biopsy. Hospitalization at CHOP had occurred for 80.4% of patients, with 45.1% ever hospitalized in an intensive care unit. One-third of children had required chronic supplemental oxygen. Seven (2.3%) patients died during this 3-year period. Collectively, these data demonstrate the scope of chILD and extent of health care utilization at a large volume tertiary care center. This approach to cohort identification and EMR-driven data collection in chILD provides new opportunities for cohort analysis and will inform the feasibility of future studies.

INTRODUCTION:Asthma and obstructive sleep apnea (OSA) are chronic diseases that disproportionately affect children with sickle cell disease (SCD). The literature describes the negative impact that both conditions have on children with SCD separately; however, the effect of OSA on asthmatic children with OSA is less specific. We hypothesized that the presence of OSA in children with SCD and asthma is associated with specific hematologic markers, worse clinical outcomes, and greater healthcare utilization. METHODS:We retrospectively evaluated children with both SCD and asthma who underwent polysomnography (PSG). We assessed their demographic information, PSG data, hematologic indices, and healthcare utilization based on the concurrent presence of OSA. RESULTS:Fifty-nine percent of the cohort had OSA with a lower oxygen saturation (SpO2 ) nadir (87% vs. 93%, p < 0.001) and a lower median daytime SpO2 (96.5% vs. 98.5%, p < 0.05); those with OSA were more likely to have the hemoglobin SS genotype (86% vs. 46.5%, p = 0.03). Additionally, those with OSA had a higher mean corpuscular volume (87 vs. 77.2 fL, p = 0.03) and reticulocyte count (10.1% vs. 5.5%, p < 0.01). There was no difference in asthma severity or healthcare utilization between those with OSA and those without OSA. DISCUSSION:Overall, children with SCD and asthma might be at increased risk for developing OSA, and screening for sleep-disordered breathing should be incorporated as part of their routine care.

Plastic bronchitis is a term used to describe group of life-threatening disorders characterized by the presence of large obstructing casts in the airways. Eosinophilic plastic bronchitis is a subtype of plastic bronchitis that occurs mainly in children and has not been well-described in the literature. Patients may have a history of asthma or atopy, but many do not. They often present with cough and wheezing, and frequently have complete collapse of one lung seen on imaging. The severity of presentation varies depending on the location of the casts, ranging from mild symptoms to severe airway obstruction and death. Bronchoscopy is often required to both diagnose and treat this condition. A variety of medical therapies have been used, although no formal studies have evaluated their efficacy. Symptoms may resolve after initial cast removal, but in some patients, cast formation recurs. Here, we report a case series of nine patients with eosinophilic plastic bronchitis and review the existing literature of this condition.

Pulmonary physiology is a core element of pediatric pulmonology care and research. This article reviews some of the notable publications in physiology that were published in Pediatric Pulmonology in 2021 and 2022.

The COVID-19 pandemic has provided challenges to all healthcare workers. While the brunt of treating COVID-19 patients fell upon adult providers, pediatricians also experienced significant stressors and disruptions. Academic pediatricians and trainees (fellows and residents) were redeployed to manage adult patients in hospitalist and intensive care settings and/or had major changes to their clinical schedules. In this study, we aimed to describe levels of self-reported depression, anxiety, and burnout in pediatric physicians following the initial wave of the pandemic at the largest integrated health system in New York State. A cross-sectional study was conducted among pediatric physicians who cared for patients during the COVID-19 pandemic within the Northwell Health System as part of the Northwell Wellbeing Registry, a longitudinal registry assessing the psychological impact of COVID-19 on healthcare providers. A total of 99 pediatric physician respondents were included in this study; 72% of whom were attendings, 28% of whom were trainees. Compared to attendings, trainees reported significantly higher proportions of burnout–emotional exhaustion (p = 0.0007) and burnout–depersonalization (p = 0.0011) on the Abbreviated Maslach Burnout Inventory. There was not a similar trend in probable depression or probable anxiety using the Patient Health Questionnaire. In a multivariable logistic regression model, being a trainee was significantly associated with increased odds of burnout–emotional exhaustion (OR 5.94, 95% Confidence Interval: 1.85–19.02). These findings suggest that fellows and residents were a vulnerable population during the COVID-19 pandemic. Training programs should pay special attention to their trainees during times of crisis, and future studies can help to identify protective factors to reduce the risk of burnout during these times.

ABSTRACT:The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.

Background Patient care events that cause emotional distress are common during pediatric training. Research has demonstrated that ICU rotations have a significant impact on trainee burnout likely in part due to the number of distressing events that occur in that environment. Interventions have been proposed by the AAP for training on peer-debriefing as well interventions to decrease distress in the ICU. Objective: Perform a needs assessment in our training program to: examine what scenarios lead to distress, assess how they are able to process these events and, have their voices be heard on how they want to be debriefed. Methods Semi-structured interviews guided by open-ended questions were conducted with 15 trainees from our large academic pediatric training program. Demographic information was collected. Data was transcribed and analyzed using a phenomenological approach. The transcribed data was coded using an iterative approach and organized into themes. Results Interviews were conducted from Aug-Dec 2019. About half of our participants were female (8, 53%) and nearly all were senior residents PGY 2(8, 53%), PGY-3 (6, 40%). Trainees experienced distressing cases either in the NICU or PICU. Based on data analysis, these cases elicited feelings of shock, loneliness, helplessness, or fear. Currently, residents receive untrained support from their peers and families and are additionally challenged by the lack of protected time to debrief the event. A common theme revealed that the trainees expect a debrief from the service faculty to assist them in processing these events. The lack of intervention by the service faculty contributes to a higher level of distress in our trainees. When describing their ideal debrief, they all agreed that the emotional debrief should stand alone from a medical debrief. Conclusions Emotionally charged patient care events have a strong impact on trainees and lead to higher rates of burnout. We plan to use this data to support peer-training in debriefing, as well as to develop a framework for service faculty to use to debrief these events with our trainees. Patient care events that cause emotional distress are common during pediatric training. Research has demonstrated that ICU rotations have a significant impact on trainee burnout likely in part due to the number of distressing events that occur in that environment. Interventions have been proposed by the AAP for training on peer-debriefing as well interventions to decrease distress in the ICU. Objective: Perform a needs assessment in our training program to: examine what scenarios lead to distress, assess how they are able to process these events and, have their voices be heard on how they want to be debriefed. Semi-structured interviews guided by open-ended questions were conducted with 15 trainees from our large academic pediatric training program. Demographic information was collected. Data was transcribed and analyzed using a phenomenological approach. The transcribed data was coded using an iterative approach and organized into themes. Interviews were conducted from Aug-Dec 2019. About half of our participants were female (8, 53%) and nearly all were senior residents PGY 2(8, 53%), PGY-3 (6, 40%). Trainees experienced distressing cases either in the NICU or PICU. Based on data analysis, these cases elicited feelings of shock, loneliness, helplessness, or fear. Currently, residents receive untrained support from their peers and families and are additionally challenged by the lack of protected time to debrief the event. A common theme revealed that the trainees expect a debrief from the service faculty to assist them in processing these events. The lack of intervention by the service faculty contributes to a higher level of distress in our trainees. When describing their ideal debrief, they all agreed that the emotional debrief should stand alone from a medical debrief. Emotionally charged patient care events have a strong impact on trainees and lead to higher rates of burnout. We plan to use this data to support peer-training in debriefing, as well as to develop a framework for service faculty to use to debrief these events with our trainees.

In this study, we describe clinical presentations of 3 febrile infants <2 months of age hospitalized in a New York pediatric hospital. We describe 3 febrile infants <2 months of age admitted to a large tertiary care children's hospital in New York and subsequently found to be infected with severe acute respiratory syndrome coronavirus 2. All 3 patients presented with fever, feeding difficulty, lymphopenia, and thrombocytosis on laboratory evaluation. Two of the 3 patients were found to have neutropenia, and 2 had known exposures to sick contacts. In this case series, we describe 3 of the youngest patients to be reported with severe acute respiratory syndrome coronavirus 2 in the United States.

Background Residents value feedback as a way to understand and improve their performance, however most trainees receive inadequate feedback. In our institution, one third of senior residents (SR) and interns report receipt of peer-to-peer feedback. Barriers to effective feedback include time, inadequate peer training, unactionable feedback, discomfort and lack of a reciprocal conversation. Implementation of a standardized process that limits these barriers may provide residents with an improved feedback experience. Aim Statement (1) To improve the frequency of feedback from SR to interns by 50% by March 2020. (2) To improve the quality of feedback such that 70% of encounters are perceived as timely, specific, actionable, and personalized by March 2020. Interventions We identified key drivers and conducted sequential Plan-Do-Study-Act (PDSA) cycles to improve the quantity and quality of peer-to-peer feedback. Interventions included (1) creation of intern learning objectives, (2) assessment of feedback, (3) SR orientation, and (4) bimonthly protected time to provide feedback. Measures The primary outcome measure was the percentage of feedback completed by interns and SR. A secondary outcome measure was the percentage of feedback that was perceived as at least very (4 out of 5 on a Likert Scale) timely, specific, actionable, and personalized. Results Surveys collected from June 2019 through Nov 2019 did not meet the 50% improvement goal for intern reported feedback frequency. SR reported feedback increased during one out of six rotations. However, after the first PDSA cycle, interns consistently perceived the feedback they received as very or extremely timely, specific, actionable, and personalized greater than 70% of the time (Fig 1). SR felt similarly about their delivered feedback, except they did not consistently feel that the feedback was actionable. Conclusions and Next Steps Implementation of a standardized feedback process did not result in increased feedback frequency but did effectively improve the quality of peer-to-peer feedback. Future steps include a PDSA cycle consisting of an on-demand educational video on effective feedback strategies for SR that may result in increased feedback frequency. Residents value feedback as a way to understand and improve their performance, however most trainees receive inadequate feedback. In our institution, one third of senior residents (SR) and interns report receipt of peer-to-peer feedback. Barriers to effective feedback include time, inadequate peer training, unactionable feedback, discomfort and lack of a reciprocal conversation. Implementation of a standardized process that limits these barriers may provide residents with an improved feedback experience. (1) To improve the frequency of feedback from SR to interns by 50% by March 2020. (2) To improve the quality of feedback such that 70% of encounters are perceived as timely, specific, actionable, and personalized by March 2020. We identified key drivers and conducted sequential Plan-Do-Study-Act (PDSA) cycles to improve the quantity and quality of peer-to-peer feedback. Interventions included (1) creation of intern learning objectives, (2) assessment of feedback, (3) SR orientation, and (4) bimonthly protected time to provide feedback. The primary outcome measure was the percentage of feedback completed by interns and SR. A secondary outcome measure was the percentage of feedback that was perceived as at least very (4 out of 5 on a Likert Scale) timely, specific, actionable, and personalized. Surveys collected from June 2019 through Nov 2019 did not meet the 50% improvement goal for intern reported feedback frequency. SR reported feedback increased during one out of six rotations. However, after the first PDSA cycle, interns consistently perceived the feedback they received as very or extremely timely, specific, actionable, and personalized greater than 70% of the time (Fig 1). SR felt similarly about their delivered feedback, except they did not consistently feel that the feedback was actionable. Implementation of a standardized feedback process did not result in increased feedback frequency but did effectively improve the quality of peer-to-peer feedback. Future steps include a PDSA cycle consisting of an on-demand educational video on effective feedback strategies for SR that may result in increased feedback frequency.

The millennial learner has a characteristic learning style. Studies have shown that millennial's want their teaching to be creative, and to take place in an informal, relaxed environment. Millennial's spend upwards of 2.5 hours on social media each day. Chief residents at a large pediatric residency program (101 residents) created a private, resident-only Instagram page through which educational material is delivered. The objective of this study is to demonstrate the utility of social media for the advancement of medical education. On the account, “One Minute Teaching” stories were posted on a regular basis. Topics were chosen by the pediatric residents. Examples include stories on pyloric stenosis, mastoiditis, and Henoch-Schonlein Purpura. At the beginning of the 2019-2020 academic year, a series of “Tips and Tricks of the Electronic Medical Record (EMR)” was also presented to introduce the incoming interns to several basic best practices for using the EMR. Stories were created by both the chief residents and pediatric third year residents during a dedicated “Resident as Teachers” rotation. After the stories were posted, viewers were surveyed if they felt the information presented was helpful in a yes/no poll. To date, eight clinical “One Minute Teaching” stories and seven “Tips and Tricks of the EMR” stories have been created and posted. An average of 40 residents watched each clinical teaching story and 51 residents watched each EMR teaching story. 99% of residents who viewed the clinical teaching stories and 98% of residents who viewed the EMR teaching stories reported that they found the information helpful. Social media is heavily used by the millennial population, but has not yet been largely adopted for use in a teaching capacity, specifically in medical education. The success of this large pediatric residency program in using Instagram to teach focused, clinically-relevant topics suggests that there is a role for social media to be used in this teaching context. The millennial learner has a characteristic learning style. Studies have shown that millennial's want their teaching to be creative, and to take place in an informal, relaxed environment. Millennial's spend upwards of 2.5 hours on social media each day. Chief residents at a large pediatric residency program (101 residents) created a private, resident-only Instagram page through which educational material is delivered. The objective of this study is to demonstrate the utility of social media for the advancement of medical education. On the account, “One Minute Teaching” stories were posted on a regular basis. Topics were chosen by the pediatric residents. Examples include stories on pyloric stenosis, mastoiditis, and Henoch-Schonlein Purpura. At the beginning of the 2019-2020 academic year, a series of “Tips and Tricks of the Electronic Medical Record (EMR)” was also presented to introduce the incoming interns to several basic best practices for using the EMR. Stories were created by both the chief residents and pediatric third year residents during a dedicated “Resident as Teachers” rotation. After the stories were posted, viewers were surveyed if they felt the information presented was helpful in a yes/no poll. To date, eight clinical “One Minute Teaching” stories and seven “Tips and Tricks of the EMR” stories have been created and posted. An average of 40 residents watched each clinical teaching story and 51 residents watched each EMR teaching story. 99% of residents who viewed the clinical teaching stories and 98% of residents who viewed the EMR teaching stories reported that they found the information helpful. Social media is heavily used by the millennial population, but has not yet been largely adopted for use in a teaching capacity, specifically in medical education. The success of this large pediatric residency program in using Instagram to teach focused, clinically-relevant topics suggests that there is a role for social media to be used in this teaching context.

Patients with sickle cell disease (SCD) are living longer and subsequently more apt to develop cardiopulmonary dysfunction. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels have been used in adults with SCD to assess for pulmonary hypertension and mortality. While the incidence of PH is low in pediatrics, it is reasonable to presume that NT-proBNP levels can be used to assess risk for the development of cardiopulmonary morbidity. We hypothesized that NT-proBNP levels would be increased in patients with SCD compared to age-adjusted healthy children; additionally, these levels would be associated with labs indicative of hemolysis and would demonstrate evidence of obstructive lung disease and cardiac dysfunction. We retrospectively evaluated patients with SCD, 8-18 years old, at a large, tertiary care children's hospital. NT-proBNP levels were assessed in correlation with hemolytic lab work, spirometry, and echocardiographic data. The age group 8-14 years old, 75% of our cohort's population, had a median NT-proBNP of 70 pg/ml, greater than their age-adjusted counterparts (52 pg/ml). NT-proBNP levels were associated with an increased degree of hemolysis when compared with hemoglobin (Hb) (r = -0.43, p < .0001), reticulocyte count (r = .25, p = .01) and lactate dehydrogenase levels (r = .47, p < .0001). An inverse trend was found between NT-proBNP and spirometric data. Finally, a positive correlation was found between NT-proBNP and diastolic left ventricular size (r = .28, p = .047]. The correlations found suggest that NT-proBNP may be used prospectively to identify patients with SCD at increased risk for the development of cardiopulmonary dysfunction.

Pediatric acute care delivery is an essential learned skill in residency training. Simulation-based training allows trainees to build upon knowledge and improve technical skills. Our training program has previously shown that low-fidelity simulation enhances situational awareness and trainee comfort, but the extent of clinical performance improvement is unknown. The objectives are to demonstrate improved competence in acute care clinical performance and to improve teamwork and communication during high-stress, high-acuity clinical situations. Weekly simulation-based case scenarios were led on three inpatient units. Each unit performed one unique clinical scenario per week, for a total of four per month. These included status epilepticus, anaphylaxis, respiratory failure, and cardiac arrest. These same four cases were repeated monthly with different residents. An intern was designated as a front-line provider, and a senior resident was available. A low-fidelity mannequin and resuscitative equipment were used. Case-specific checklists containing required clinical steps and key communication concepts were completed followed by a structured debrief. Data collected from Aug 2019 through Dec 2019 reflects an improvement in both clinical achievement and communication from week to week within the same resident group (Fig 1). The average percentage of completed case-specific clinical steps at week 1 was 58% and by week 4 was 85%. The average percentage of communication components achieved at week 1 was 52% and by week 4 was 78%. This study demonstrates sustained improvement in acute care delivery over the course of a single inpatient block. The improvement in clinical competency and communication over a four-week period suggests that resident performance is enhanced with frequent in-situ simulation and with teamwork within the same resident cohort. We believe these results solidify the utility of standardized cases and structured debriefs to effectively train residents on acute clinical care. Further steps include assessment of resident achievement in acute care simulation over several months to evaluate long-term improvement and sustainability. Pediatric acute care delivery is an essential learned skill in residency training. Simulation-based training allows trainees to build upon knowledge and improve technical skills. Our training program has previously shown that low-fidelity simulation enhances situational awareness and trainee comfort, but the extent of clinical performance improvement is unknown. The objectives are to demonstrate improved competence in acute care clinical performance and to improve teamwork and communication during high-stress, high-acuity clinical situations. Weekly simulation-based case scenarios were led on three inpatient units. Each unit performed one unique clinical scenario per week, for a total of four per month. These included status epilepticus, anaphylaxis, respiratory failure, and cardiac arrest. These same four cases were repeated monthly with different residents. An intern was designated as a front-line provider, and a senior resident was available. A low-fidelity mannequin and resuscitative equipment were used. Case-specific checklists containing required clinical steps and key communication concepts were completed followed by a structured debrief. Data collected from Aug 2019 through Dec 2019 reflects an improvement in both clinical achievement and communication from week to week within the same resident group (Fig 1). The average percentage of completed case-specific clinical steps at week 1 was 58% and by week 4 was 85%. The average percentage of communication components achieved at week 1 was 52% and by week 4 was 78%. This study demonstrates sustained improvement in acute care delivery over the course of a single inpatient block. The improvement in clinical competency and communication over a four-week period suggests that resident performance is enhanced with frequent in-situ simulation and with teamwork within the same resident cohort. We believe these results solidify the utility of standardized cases and structured debriefs to effectively train residents on acute clinical care. Further steps include assessment of resident achievement in acute care simulation over several months to evaluate long-term improvement and sustainability.

Quality Improvement (QI) science focuses on how healthcare is delivered (process measures) and the results (outcome measures). Although instruction in QI methodology is recognized as an important part of a resident's education, maintaining resident engagement is a challenge. A Resident Quality Council (RQC) was established to (1) create and maintain a resident-generated and relevant quality dashboard, (2) enhance resident awareness of in-hospital QI initiatives, and (3) increase QI scholarly activity among residents. A RQC was established in 2017 consisting of five resident champions and three chief residents, mentored by program leadership, a Chief Quality Officer, and QI staff. To increase resident engagement a continuously updated resident-inspired dashboard, which highlighted both quality and operational standards, was created. Metrics were chosen based on resident feedback. Over 18 months, a lecture series was introduced into the residency curriculum which highlighted various QI initiatives with a special focus on process and outcome measures related to the dashboard. At the start of the 2019-2020 academic year, the RQC surveyed residents in regards to their level of QI engagement and the utility of the dashboard as part of the residency curriculum. The most relevant metrics, as reported, included asthma guidelines, length of stay, and number of safety events. There was a reported increase in understanding of a dashboard's utility from 15.8% to 78.3% (N = 23). 78% reported continued interest in the maintenance of a dashboard with resident-pertinent metrics and acknowledged that the dashboard contributed to their understanding of the significance of QI science. Lastly, 87% felt the knowledge presented to them through the dashboard directly resulted in their increased interest in in-hospital QI initiatives and their desire to partake in QI scholarly work. Establishment of an RQC has proven beneficial in promoting QI interest amongst residents. Resident-pertinent dashboard metrics have kept housestaff engaged and interested in expanding their QI fund of knowledge through QI-driven scholarly projects.

Residents are exposed to medical errors during their training. The ACGME emphasizes the importance of patient safety and medical error analysis in a residency curriculum. Understanding root cause analysis (RCA) is an important component of a morbidity, mortality, and improvement (MMI) curriculum, enriching patient safety education. The objectives are to (1) engage residents in a mock RCA, (2) increase resident comfort in reporting medical errors, and (3) increase resident awareness of patient safety opportunities. Our MMI curriculum incorporated a mock-RCA workshop which highlighted a medical error that occurred due to poor patient hand-off. Residents assumed multiple roles (including that of chief quality officer) and were guided through an RCA. They identified the safety event, deviations from standard of care, and corrective actions to mitigate recurrence. Using a 5-point Likert scale survey, we assessed residents on their understanding of the RCA process, confidence in identifying safety events and deviations in care, willingness to report a medical error, and perceived ability to identify QI opportunities in the workplace. 100% strongly agreed or agreed that they had a better understanding of the RCA process (n = 20). 95% either strongly agreed or agreed that they felt confident in identifying safety events and deviations in care. Regarding likelihood to self-report a medical error or one made by a colleague, 95% strongly agreed or agreed with both statements. All residents strongly agreed or agreed with their ability to identify QI opportunities in day-to-day patient care. Lastly, 85% either strongly agreed or agreed that they had become more actively interested in participating in a QI project involving patient safety. Medical errors provide opportunities for residents to learn and take corrective actions. An MMI curriculum, focused through the lens of an RCA, is an opportunity for residents to gain a better understanding of how medical errors are identified and engage residents in QI science on a hospital-wide level. Residents are exposed to medical errors during their training. The ACGME emphasizes the importance of patient safety and medical error analysis in a residency curriculum. Understanding root cause analysis (RCA) is an important component of a morbidity, mortality, and improvement (MMI) curriculum, enriching patient safety education. The objectives are to (1) engage residents in a mock RCA, (2) increase resident comfort in reporting medical errors, and (3) increase resident awareness of patient safety opportunities. Our MMI curriculum incorporated a mock-RCA workshop which highlighted a medical error that occurred due to poor patient hand-off. Residents assumed multiple roles (including that of chief quality officer) and were guided through an RCA. They identified the safety event, deviations from standard of care, and corrective actions to mitigate recurrence. Using a 5-point Likert scale survey, we assessed residents on their understanding of the RCA process, confidence in identifying safety events and deviations in care, willingness to report a medical error, and perceived ability to identify QI opportunities in the workplace. 100% strongly agreed or agreed that they had a better understanding of the RCA process (n = 20). 95% either strongly agreed or agreed that they felt confident in identifying safety events and deviations in care. Regarding likelihood to self-report a medical error or one made by a colleague, 95% strongly agreed or agreed with both statements. All residents strongly agreed or agreed with their ability to identify QI opportunities in day-to-day patient care. Lastly, 85% either strongly agreed or agreed that they had become more actively interested in participating in a QI project involving patient safety. Medical errors provide opportunities for residents to learn and take corrective actions. An MMI curriculum, focused through the lens of an RCA, is an opportunity for residents to gain a better understanding of how medical errors are identified and engage residents in QI science on a hospital-wide level.

The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.

Abstract The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.