Background The study assessed a distance simulation and education intervention designed to improve nursing empowerment in the pediatric intensive care unit (PICU) in Korle Bu Teaching Hospital (KBTH) in Ghana. Methods This was a single center, mixed methods, longitudinal simulation-based pilot study. A distance pediatric critical care nursing curriculum that combined interactive learning via Zoom and distance simulation using the Virtual Resus Room was designed and delivered from the United States to KBTH PICU nursing staff. Results The Clinical Teamwork Scale, used to assess team performance after each simulation, demonstrated an upward trend over time in all categories. The modified Simulation Effectiveness Tool was utilized to evaluate the learners' perceptions of the effectiveness of the simulation in meeting their learning objectives. Qualitative content analysis of this free-text feedback highlighted the course's educational content, organizational aspects, learning experience, simulation case scenarios and relevance to pediatric critical care in Ghana. Conclusions A distance pediatric critical care nursing curriculum, relevant to local practice and resources, was implemented through an international partnership and contributed to nursing empowerment through improved learning and confidence.

BACKGROUND:Comprehensive cleft care is a multidisciplinary team endeavor. While untreated craniofacial conditions have multiple undue repercussions, cleft care in outreach settings can be fraught with significant perioperative morbidity risks.AIM:Propose updated quality assurance standards addressing logistic and operational considerations essential for the delivery of safe and effective cleft lip and /or palate (CL/P) care in low and middle-income countries (LMICs) settings.METHODS:Based on American Cleft Palate-Craniofacial Association (ACPA) quality standards, published literature, published protocols by Global Smile Foundation (GSF), and the senior author's three-decade experience, updated standards for outreach cleft care were synthesized.RESULTS:Ten axes for safe, effective, and sustainable cleft lip and palate care delivery in underserved settings were generated: 1) site assessment, 2) establishment of community partnerships, 3) team composition and credentialing, 4) team training and mission preparation, 5) implementation of quality assurance guidelines, operative safety checklists, and emergency response protocols, 6) immediate and long-term postoperative care, 7) medical record keeping, 8) outcomes evaluation, 9) education, and 10) capacity building and sustainability. Subsequent analysis further characterized essential components of each of those ten axes to delineate experience derived and evidence-based recommendations.DISCUSSION:Quality assurance guidelines are essential for the safe delivery of comprehensive cleft care to patients with CL/P in any setting. Properly designed surgical outreach programs relying on honest community partnerships can be effectively used as vehicles for local capacity building and the establishment of sustainable cleft care ecosystems.

An 18-year-old girl with high-risk acute myeloid leukemia developed Streptococcus mitis septic shock and multiorgan dysfunction syndrome, including biventricular failure. Due to the anticipated reversibility of her cardiogenic shock, her young age, and her favorable survival chance after an allogeneic hematopoietic stem cell transplant, she was placed on full circulatory support with venoarterial extracorporeal membrane oxygenation as a bridge to her successful hematopoietic stem cell transplantation 2 months later. This highlights the importance of prognostication in patient selection for extracorporeal life support. A multidisciplinary approach is essential to each case until more definite initiation criteria, risk stratification, and treatment protocols are established.

Simulation is a well-studied teaching tool for multidisciplinary teamwork, crisis resource management, and communication skills. These attributes are essential for successful international medical missions, which include healthcare providers with different familiarities with the outreach environment and each team member's role. However, immersive simulation remains underused in similar settings. Our team designed a simulation-based curriculum that focuses on multidisciplinary teamwork and crisis resource management skills. In this commentary, we describe its implementation during high-risk cleft care outreach missions conducted by the Global Smile Foundation. We discuss the importance of a simple, feasible, and flexible platform to successfully overcome the limitations of time and resources inherent to outreach mission work while addressing the clinical and geographic needs specific to each site. We highlight challenges, including unpredictability of the outreach environment, a language barrier, and the short duration of missions. Finally, we offer a roadmap for groups involved in similar global health efforts.

Introduction: The authors analyzed the insights of participants and faculty members of Global Smile Foundation's Comprehensive Cleft Care Workshops concerning the barriers and interventions to multidisciplinary cleft care delivery, after stratification based on demographic and geographic factors. Methods: During 2 simulation-based Comprehensive Cleft Care Workshops organized by Global Smile Foundation, participants and faculty members filled a survey. Surveys included demographic and geographic data and investigated the most relevant barrier to multidisciplinary cleft care and the most significant intervention to deliver comprehensive cleft care in outreach settings, as perceived by participants. Results: The total response rate was 57.8%. Respondents reported that the greatest barrier to comprehensive cleft care was financial, and the most relevant intervention to deliver multidisciplinary cleft care was building multidisciplinary teams. Stratification by age, gender, and geographical area showed no statistical difference in reporting that the greatest barrier to cleft care was financial. However, lack of multidisciplinary teams was the most important barrier according to respondents with less than 5 years of experience ( P = 0.03). Stratification by gender, years in practice, specialty, and geographical area showed no statistical difference, with building multidisciplinary teams reported as the most significant intervention. However, increased training was reported as the main intervention to cleft care for those aged less than 30 years old ( P = 0.04). Conclusions: Our study delivers an assessment for barriers facing multidisciplinary cleft care delivery and interventions required to improve cleft care delivery. The authors are hoping that stratification by demographic and geographic factors will help them delineate community-specific road maps to refine cleft care delivery.

Supplemental digital content is available in the text. Summary Statement Simulation is a well-studied teaching tool for multidisciplinary teamwork, crisis resource management, and communication skills. These attributes are essential for successful international medical missions, which include healthcare providers with different familiarities with the outreach environment and each team member's role. However, immersive simulation remains underused in similar settings. Our team designed a simulation-based curriculum that focuses on multidisciplinary teamwork and crisis resource management skills. In this commentary, we describe its implementation during high-risk cleft care outreach missions conducted by the Global Smile Foundation. We discuss the importance of a simple, feasible, and flexible platform to successfully overcome the limitations of time and resources inherent to outreach mission work while addressing the clinical and geographic needs specific to each site. We highlight challenges, including unpredictability of the outreach environment, a language barrier, and the short duration of missions. Finally, we offer a roadmap for groups involved in similar global health efforts.

Kantar, Rami S. MD, MPH; Chahine, Elsa M. MD; Alfonso, Allyson R. BS, BA; Nader, Marie K. MD; Annan, Beyhan MPH, MD; Haddad, Anthony G. MD; Hamdan, Usama S. MDAuthor Information

Objective: To describe the conduct of the first multidisciplinary simulation-based workshop in the Middle East/North Africa region and evaluate participant satisfaction. Design: Cross-sectional survey-based evaluation. Setting: Educational comprehensive multidisciplinary simulation-based cleft care workshop. Participants: Total of 93 workshop participants from over 20 countries. Interventions: Three-day educational comprehensive multidisciplinary simulation-based cleft care workshop. Main Outcome Measures: Number of workshop participants, number of participants stratified by specialty, satisfaction with workshop, number of workshop staff, and number of workshop staff stratified by specialty. Results: The workshop included 93 participants from over 20 countries. The response rate was 47.3%, and participants reported high satisfaction with all aspects of the workshop. All participants reported they would recommend it to colleagues (100.0%) and participate again (100.0%). No significant difference was detected based on participant specialty or years of experience. The majority were unaware of other cleft practitioners in their countries (68.2%). Conclusion: Multidisciplinary simulation-based cleft care workshops are well received by cleft practitioners in developing countries, serve as a platform for intellectual exchange, and are only possible through strong collaborations. Advocates of international cleft surgery education should translate these successes from the regional to the global arena in order to contribute to sustainable cleft care through education.

BACKGROUND:Diabetes devices provide data for health care providers (HCPs) and people with type 1 diabetes to make management decisions. Extracting and viewing the data require separate, proprietary software applications for each device. In this pilot study, we examined the feasibility of using a single software platform (Tidepool) that integrates data from multiple devices. MATERIALS AND METHODS:Participating HCPs (n = 15) used the software with compatible devices in all patient visits for 6 months. Samples of registration desk activity and office visits were observed before and after introducing the software, and HCPs provided feedback by survey and focus groups. RESULTS:The time required to upload data and the length of the office visit did not change. However, the number of times the HCP referred to the device data with patients increased from a mean of 2.8 (±1.2) to 6.1 (±3.1) times per visit (P = 0.0002). A significantly larger proportion of children looked at the device data with the new application (baseline: 61% vs. study end: 94%, P = 0.015). HCPs liked the web-based user interface, integration of the data from multiple devices, the ability to remotely access data, and use of the application to initiate patient education. Challenges included the need for automated data upload and integration with electronic medical records. CONCLUSIONS:The software did not add to the time needed to upload data or the length of clinic visits and promoted discussions with patients about data. Future studies of HCP use of the application will evaluate clinical outcomes and effects on patient engagement and self-management.

Glucose meters, insulin pumps, and continuous glucose monitoring systems provide data needed for people with type 1 diabetes to modify insulin regimens, evaluate lifestyle changes, or troubleshoot unexpected glucose levels. Health care providers (HCPs) can use device-specific software to review data at patient visits, often using separate, proprietary applications for each device. Using mixed qualitative and quantitative methods, we examined the feasibility of using the Tidepool platform and web application to view diabetes data from multiple devices together, in a multidisciplinary pediatric diabetes center where it was standard practice to upload and view data using device-specific software for each patient visit. Participating HCPs (n=15) used the software with compatible devices in all patient visits for 6 months. To evaluate the effect of the application on workflow, registration desk activity and office visits were observed before and after introducing the software, and HCPs provided feedback by survey and focus groups. The time required to upload device data and the length of the office visit did not change. However, the number of times the provider referred to the device data with patients increased from a mean of 2.8 (±1.2) to 6.1 (±3.1) times per observed visit (p=0.0002). A significantly larger proportion of the children looked at the device data with the new application (61% at baseline vs. 94% at study end, p=0.015). HCPs liked the use of color to indicate glucose levels, the graphical web-based user interface, integration of the data in one application, and the ability to remotely access data via the web for telehealth. They found the application most useful for initiating patient conversations and education. Remaining challenges include the need for automated data upload and integration with electronic medical records. Future studies of HCP use of the application will focus on clinical outcomes and effects on patient engagement and self-management. Disclosure J.C. Wong: Research Support; Self; Dexcom, Inc.. Other Relationship; Self; Tidepool Project. Z. Izadi: None. S.M. Schroeder: None. M. Nader: None. H.J. Min: None. A.B. Neinstein: None. S. Adi: Stock/Shareholder; Spouse/Partner; Dexcom, Inc.. Speaker's Bureau; Self; Dexcom, Inc.. Board Member; Self; Tidepool Project. Other Relationship; Self; Novo Nordisk Inc..

When using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN-IMF1 (simplified evaluation system), SN-IMF2 (High Five System), and SN-IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands.