Aligning the Pediatric EM Research Agenda

Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps May 15, 2018 JW Marriott Indianapolis

#AEMCC #SAEM18

Funding for this conference was made possible in part by grant number 1R13HS026101-01 from the Agency for Healthcare Research and Quality (AHRQ) and Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award EAIN-6161. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services or PCORI; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

We would like to thank the following organizations, departments, and individuals for their generous support of this consensus conference:

TABLE OF CONTENTS 2018 AEM Consensus Conference “Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps�

Section

Page

Consensus Conference Disclosures and Resolutions, CME Statement

4

Mission, Goals, Objectives

5

Welcoming Remarks

6

A History of the Academic Emergency Medicine Consensus Conference

7

Save the Date: 2019 Consensus Conference

8

Agenda

9

Conference Co-Chairs

10

Speaker Biographies

11

Patient Advocate Stories

12

Breakout Themes

19

Organizing Committee

24

Acknowledgements

26

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2018 AEM CONSENSUS CONFERENCE DISCLOSURES AND RESOLUTIONS The following speakers and planning committee members have no relationships to disclose.

Jeffrey Kline, MD, Indiana University Maybelle Kou, MD, Inova Children's Hospital Prashant Mahajan, MD, MPH, MBA, University of Michigan Kim Mears Chris Merritt, MD, MPH, Brown University, Alpert Medical School/Hasbro Children's Hospital Rakesh Mistry, MD, MS, Children's Hospital Colorado Parris Shelley Michael Stoner, MD Susan P. Tyler, University of Cincinnati, Director of CME

Kathleen Adelgais, MD, MPH Mary Kay Ballasiotes Isabel Barata, MS, MD, MBA, Northwell Health System Robert Cloutier, MD, MCR Kurt Denninghoff, MD, University of Arizona Paula Denslow Troy Denslow Bruce Gebhardt, MD, University of Cincinnati, CME Paul Ishimine, MD, University of California San Diego Nathan Kuppermann, MD, MPH, University of California Davis School of Medicine Terry Klassen, MD, MSc, FRCPC Jean Klig, MD

The following speakers and planning committee members have relationships to disclose.

None

CME STATEMENT Joint Accreditation Statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Society of Academic Emergency Medicine. The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians. The University of Cincinnati designates this live activity for a maximum of 8 AMA PRA Category 1 Credits™. Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Faculty Disclosure Declaration: According to the disclosure policy of the University Of Cincinnati College Of Medicine, all faculty, planning committee members, and other individuals who are in a position to control content are required to disclose any relevant relationships with any commercial interest related to this activity. The existence of these interests or relationships is not viewed as implying bias or decreasing the value of the presentation, and any conflict of interest is resolved prior to the activity. All educational materials are reviewed for fair balance, scientific objectivity and levels of evidence. Disclosure will be made at the time of the activity.

Learner Assurance Statement: The University of Cincinnati is committed to resolving all conflicts of interest issues that could arise as a result of prospective faculty members’ significant relationships with drug or device manufacturer(s). The University of Cincinnati is committed to retaining only those speakers with financial interests that can be reconciled with the goals and educational integrity of the CME activity.

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MISSION Health outcome gaps are disproportionately increasing in the pediatric population. Many social and clinical factors contribute to this growing disparity. According to Robert Wood Johnson Foundation County Health Ranking and Roadmaps from 2015, children are at higher risk of poor health outcomes because social determinants such as poverty, education, and geographic location create barriers. The clinical factors associated with these differences are numerous and include access to care, variability in provider training and organizational readiness. Most critically ill children who present for emergency care are initially seen in general emergency departments (EDs), that is, EDs that do not specifically focus just on the care of ill and injured children. These children are managed by emergency physicians, who need to be versed in pediatric care. In addition, pediatric tertiary care centers tend be located in urban regions, with regional variability in placement and numbers. Thus, emergency providers who take care of children have a unique view into the nexus of healthcare, policy, and social determinants of health. These physicians come from multiple training pathways from emergency medicine and pediatrics, and represent many specialty organizations at the regional, national, and international level. There is a critical need for collaboration among these physicians. Though there is depth to the specialty, it is the different pathways to training have led to an isolated approach to both research needs and practice dissemination.

GOALS

The overarching goal of this consensus conference is to develop the pediatric emergency medicine (PEM) research agenda for the next decade in order to reduce health outcome gaps in ill and injured children. The consensus conference will bring together thought leaders and practitioners across multiple organizations that influence pediatric research and practice. The conference will consist of state-of-the-art didactics, small group planning sessions, and Delphi expert consensus techniques. Specific topics that will be explored are: 1) pediatric emergency medical services research, 2) pediatric emergency research network collaboration, 3) pediatric emergency medicine education for emergency medicine providers, 4) workforce development for pediatric emergency medicine, and 5) pediatric emergency medicine practice in non-children’s hospitals. The payoff is to strengthen the collaborative exchange of ideas among PEM practitioners, in order to prioritize research agendas and best practices.

OBJECTIVES In order to achieve the overarching goal, this consensus conference has three specific aims: Aim 1: Align PEM leaders across organizations and foster new leadership.

• Leaders from Pediatric Emergency Care and Research Network (PECARN) and Pediatric Emergency Research Canada (PERC) will identify common goals and synergies between organizations. The impact of this alignment will help identify leadership in pediatric emergency care.

Aim 2: Develop a research agenda for PEM across all access points into the emergency care system and promote pediatric emergency expertise via education among its workforce.

• The end result would be identification of the best practices, with its translation into clinical practice, by its dissemination among practitioners who care for children.

Aim 3: Integrate PEM research networks.

• This integration will focus upon identifying trends and resolving issues that may shape the practice of pediatric emergency care in the upcoming decade. The end result of integration will allow for a pooling of resources.

This consensus conference will promote collaboration among thought leaders and practitioners, identification of areas for future study and translation of best practices and dissemination of these practices to those who care for children.

The expectation of these efforts is to improve health outcomes in children and to reduce disparities in pediatric emergency care.

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WELCOMING REMARKS Dear Colleagues, We are thrilled to welcome each of you to the 2018 Academic Emergency Medicine Consensus Conference “Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps.” As the first SAEM Consensus Conference focusing on the care of ill and injured children, we are excited to have a unique conference that brings together leaders in emergency medical services, emergency medicine, pediatrics, pediatric emergency medicine, and patient advocacy. While these parties have always been unified in their purpose of improving the emergency care we provide to children, efforts to achieve this end have often been less effective because they were disconnected and, occasionally, even in conflict. The overarching goal of this conference is to bring together thought leaders from these groups and to collectively generate a prioritized list of areas or gaps that represent opportunities for high-impact, focused future research in pediatric emergency medicine.

A conference as important as this one has required substantial amounts of work by many contributors. First, we wish to thank the members of the Consensus Conference Planning Committee for their contributions to this monumental effort.

We are especially grateful for the subcommittee chairs: Kathleen Adelgais, MD, MPH; Isabel Barata, MS, MD, MBA; Jean Klig, MD; Maybelle Kou, MD; Prashant Mahajan, MD, MPH, MBA; Chris Merritt, MD, MPH, and Michael Stoner, MD. Their commitment has been unwavering, and the time and expertise they have contributed has been incalculable.

We would like to extend our gratitude to the keynote speakers, Nate Kuppermann, MD, MPH and Terry Klassen, MD, MSc; and the patient advocates, moderators, and scribes for contributing their knowledge and stories to this conference. We recognize Jennifer Walthall, MD, MPH, who conceived the idea for this conference, brought together the original planning committee, and submitted the initial Consensus Conference proposal to the SAEM Board. We would like to thank the Editor-in-Chief of Academic Emergency Medicine (AEM), Jeff Kline, MD and the guest editors for the upcoming consensus conference issue of AEM, Rakesh Mistry, MD, MS and Robert Cloutier, MD, MCR, for their guidance. We also appreciate the support of our families and friends, as well as our colleagues in the Department of Emergency Medicine at University of Arizona, the Division of Pediatric Emergency Medicine at Rady Children’s Hospital, San Diego and the Department of Emergency Medicine at the University of California, San Diego. We would also like to extend our deepest appreciation to Melissa McMillian, CNP, the SAEM Staff Liaison, whose experience helping organize previous Consensus Conferences has provided an invaluable guide to the planning of this year’s conference.

Additionally, we are grateful for the generous grant support from the Agency for Healthcare Research and Quality, and the Patient Centered Outcomes Research Institute. We also greatly appreciate the sponsorship of the American College of Emergency Physicians; PM Pediatrics; LifeFlow; the National Registry of Emergency Medical Technicians; the Departments of Emergency Medicine at Brown University and the University of California, Davis; and the Division of Pediatric Emergency Medicine at Nationwide Children’s Hospital. The financial support from these organizations made this conference possible.

Finally, this conference could not have happened without you, the conference participant. We hope that you liberally contribute your thoughts and experience so that the research agenda we create together will help catalyze future study.

We strongly believe that the greatest potential benefit of this conference will be the connections you make fostering future collaborations that unite our efforts to improve the emergency care of children. We look forward to a productive conference, and we thank you for your participation.

Academic Emergency Medicine Consensus Conference Co-Chairs Paul Ishimine, MD Kurt Denninghoff, MD Clinical Professor of Emergency Medicine and Pediatrics Distinguished Professor of Emergency Medicine Departments of Emergency Medicine and Pediatrics Department of Emergency Medicine University of California, San Diego University of Arizona 6

A HISTORY OF THE ACADEMIC EMERGENCY MEDICINE CONSENSUS CONFERENCE This year’s Academic Emergency Medicine (AEM) consensus conference, “Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps,” marks nineteen years of sustained disruptive innovation from dedicated emergency academicians. The conference follows a long tradition for AEM that grew from a vision that we still maintain. The editors of AEM believe that the role of medical journals goes beyond the presentation of research findings. We believe that we are in a position to elevate the humanism of medicine by stimulating discussion about relevant topics of academic medical concern, with the hope of inspiring research in areas where current gaps exist.

With this philosophy in mind, AEM developed its first consensus conference in 2000, and has continued to offer conferences each year. The goal of the AEM consensus conference is to identify an area of emergency research and clinical need, gather thought leaders for interchange related to the current state of the field, and then develop a research agenda to advance the science on the topic at hand.

The topics presented are chosen through a competitive process and are usually developed by interest groups or committees within the Society for Academic Emergency Medicine. Thirteen of the 19 consensus conferences have been supported by federal funding. The conference proceedings are published in a special issue of AEM, and distributed electronically.

The topics that have been presented are: 2000: Errors in emergency medicine 2001: The unraveling safety net 2002: Quality and best practices in emergency care 2003: Disparities in emergency care 2004: Information technology in emergency medicine 2005: Emergency research without informed consent 2006: The science of surge 2007: Knowledge translation 2008: Simulation in emergency medicine 2009: Public health in the emergency department: surveillance, screening, and intervention 2010: Beyond regionalization: integrated networks of emergency care 2011: Interventions to assure quality in the crowded emergency department 2012: Education research in emergency medicine 2013: Global health & emergency care: a research agenda 2014: Gender-specific research in emergency medicine 2015: Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization 2016: Shared Decision Making in the Emergency Department: Development of a Policy-Relevant, PatientCentered Research Agenda 2017: Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes The downstream academic success of these conferences has been impressive. More than $400 million in federal funding has been secured for projects related to the consensus conference themes; and the consensus conference proceedings papers have been cited, on average, more than 15 times each in the peerreviewed literature.* 7

We welcome applications for 2020 and for the years to come – and we hope you will join us at the 2019 consensus conference in Las Vegas, NV: “Wellness for The Future: Cultural and Systems-Based Challenges And Solutions.”

Jeffrey A. Kline, MD, Editor-In-Chief * Nishijima DK, Dinh T, May L, Yadav K, Gaddis GM, Cone DC. Quantifying federal funding and scholarly output related to the Academic Emergency Medicine consensus conferences. Acad Med 2014;89:176-181.

SAVE THE DATE 2019 SAEM Consensus Conference Date: May 14, 2019 Title: "Wellness for The Future: Cultural and Systems-Based Challenges and Solutions" Location: The Mirage, Las Vegas, NV Co-chairs:

Rosanna Sikora, MD Rita Manfredi, MD Arlene S. Chung, MD

Mark your calendars and be sure to join us for another excellent consensus conferences. Keep watching SAEM communications for more information and updates.

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AGENDA Tuesday, May 15, 2018 7:30 am – 8:00 am

Registration and Continental Breakfast

8:00 am – 8:15 am

Opening Remarks Jeffrey Kline, MD Editor-in-Chief, Academic Emergency Medicine

8:15 am – 8:45 am

Recent Work, Setting the Agenda, Consensus Plan Kurt Denninghoff, MD and Paul Ishimine, MD AEM Consensus Conference Co-Chairs

8:45 am – 9:30 am

Keynote Address: “Generating Evidence that is Ripe for Translation: Not All Evidence is Created Equal” Nate Kuppermann, MD, MPH Bo Tomas Brofeldt Endowed Chair, Department of Emergency Medicine Distinguished Professor, Departments of Emergency Medicine and Pediatrics University of California, Davis School of Medicine

9:30 am – 9:45 am 9:45 am – 11:20 am

Break Breakout Session/Morning • Pediatric EMS Research • Pediatric Emergency Medicine Research Networks • Pediatric Emergency Medicine Education

11:20 am – 11:35 am 11:35 am – 12:35 pm

Break Lunchtime Panel: “The Power of Collaboration” Moderator: Rakesh Mistry, MD Patient Advocacy Panel • Paula Denslow, Tennessee Disability Coalition, Patient Advocate • Troy Denslow, Patient Advocate • Kim Mears, Children’s Hospital Volunteer, Patient Advocate • Mary Kay Ballasiotes, Founder/President, International Alliance for Pediatric Stroke

12:35 pm – 12:50 pm 12:50 pm – 2:30 pm

Break Breakout Session/Afternoon • Workforce Development for Pediatric Emergency Medicine • Pediatric Emergency Medicine in Non-Childrens Hospitals

2:30 pm – 2:45 pm 2:45 pm – 3:30 pm

Break Closing Address: “Reducing the Gap: Getting Evidence to the Point of Care” Terry Klassen, MD, MSc Professor and Head, Department of Pediatrics & Child Health Max Rady College of Medicine, Rady Faculty of Health Sciences University of Manitoba

3:30 pm – 4:45 pm 4:45 pm – 5:00 pm

Breakout Session Reports Closing Remarks 9

CONFERENCE CO-CHAIRS Paul Ishimine, MD, is Clinical Professor of Emergency Medicine and Pediatrics at the University of California, San Diego School of Medicine. He is the Director of the Pediatric Emergency Medicine Fellowship in the Department of Emergency Medicine at UC San Diego and in the Division of Emergency Medicine at the Rady Children’s Hospital, San Diego, and he is the Director of Pediatric Emergency Medicine at UC San Diego Health.

He is the Immediate Past Chair of the Pediatric Emergency Medicine Subboard of the American Board of Emergency Medicine and the American Board of Pediatrics. Dr. Ishimine obtained his undergraduate degree from the University of California, Berkeley and his medical degree from the University of California, Irvine. He completed an emergency medicine residency at the University of Pittsburgh and a pediatric emergency medicine fellowship at the Children’s Hospital of Philadelphia. Dr. Ishimine’s main area of interest is graduate medical education and educational policy, and his research focuses on infectious diseases in infants and young children.

Kurt Denninghoff, MD is the PECARN Southwest Research Node PI. He is an Endowed Professor of Emergency Medicine and Optics and is the Associate Head of Emergency Medicine and the Associate Director for the Arizona Emergency Medicine Research Center. He began his interest in research as an undergraduate biomedical engineering student at Vanderbilt University when he developed a design for a new very fast thermometer that did not require placing the device under the tongue or waiting 2-3 minutes for the mercury to rise. He won the program award in biomedical engineering and went on to medical school at Vanderbilt where he participated in an NIH medical student research fellowship. He then went on to do residency in emergency medicine at LSU Charity Hospital where he did decisive research into the importance of findings on rape exam and outcome in court. This study was presented as an abstract and won a regional award for resident research. After completing his residency, he completed a trial evaluating tympanic thermometry in the prehospital setting and began his research career in earnest when he won a major grant from the DOD to study retinal venous oximetry methods for possible use in trauma victims. His work with device development, PhD candidates in Optics, and early research support as a funded PI in emergency medicine (starting in 1997) has lead him to be sought after by research and faculty trainees. He has been actively engaged in developing new methods to train medical students, residents, fellows and new faculty in research methods for the last 20 years. He has also been interested in improving the clinical research environment of the emergency department. Recent work includes prehospital TBI management and care for children who wheeze.

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SPEAKER BIOGRAPHIES KEYNOTE SPEAKERS Nathan Kuppermann, MD, MPH, is a nationally recognized expert in pediatric emergency medicine. In addition to his clinical work, he has made outstanding research contributions, promoting global and national collaborations among leading pediatric emergency departments to advance the care of critically ill and injured children.

Kuppermann holds the Bo Tomas Brofeldt Endowed Chair in the Department of Emergency Medicine at UC Davis. Kuppermann is an elected member of the National Academy of Medicine (NAM). He is the principal investigator of the Pediatric Emergency Care Applied Research Network (PECARN). He also chairs the executive committee of the global Pediatric Emergency Research Network (PERN).

Terry Klassen, MD, MSc, FRCPC is CEO and Scientific Director of the Children’s Hospital Research Institute of Manitoba. He is also Head of the Department of Pediatrics and Child Health at University of Manitoba and Medical Director of Child Health Program at Winnipeg Regional Health Authority. Dr. Klassen became the CEO and Scientific Director for the Children\’s Hospital Research Institute of Manitoba and Associate Dean, Academic in the Faculty of Medicine, University of Manitoba, in charge of the George and Fay Yee Center for Healthcare Innovation in September, 2010.

From 1999 to 2009 Dr. Klassen served as Chair of the Department of Pediatrics at the University of Alberta. During the same period Dr. Klassen was the Director of the Alberta Research Centre for Health Evidence and Director of the Evidence-based Practice Center at the University of Alberta. He is a clinician scientist whose clinical base is Pediatric Emergency Medicine and has been active in Pediatric Emergency Research Canada collaborating on a national research program involving randomized controlled trials, systematic reviews and knowledge translation. He has a consistent record of national and international peer reviewed funding, along with a publication record that has included many articles in the highest impact medical journals.

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PATIENT ADVOCATES Mary Kay’s Story I’m Mary Kay Ballasiotes and I have been an advocate for pediatric stroke in various capacities for twenty years. My daughter suffered a prenatal stroke somewhere between 20 and 29 weeks gestation, so my first role was as a coordinator for her medical care. I then started a support group in the Chicago area when we lived there and am currently the founder and executive director for the International Alliance for Pediatric Stroke.

Mary Kay Ballasiotes has been an advocate for pediatric stroke for the past 20 years, after learning her third child had suffered a prenatal stroke. She started a support group for families in the Chicago area when she lived there and is now the founder and executive director for a global non-profit, International Alliance for Pediatric Stroke. Mary Kay has also been a PCORI patient reviewer and mentor since 2013, was on the DSMB for an NIH clinical trial for tPA use in children and is currently a member of the University of North Carolina Stroke Patient, Family and Community Advisory Board. Ms. Ballasiotes has partnered with the American Heart/American Stroke Association over the years to increase awareness of pediatric through co-production of medically vetted fact sheets and videos, speaking at congressional briefings and other AHA/ASA events. Mary Kay also has done many presentations at hospitals, EMS conferences and webinars to advance the education of pediatric stroke.

Most people are not aware that strokes can occur in babies, children, teens and even before birth. Educating and increasing awareness of pediatric stroke in the community – among parents, school nurses, first responders, pediatricians, and pediatric emergency physicians, to name a few – has been a key mission for our organization.

I’m here today to share the story of 4-year-old Lelaina Jaymes Fitzsimons. Her parents called her Laney. On May 7th, 2016, when Laney was just 3 ½ years old, she was at home taking a bath when her parents noticed her face was slightly drooping and she had mild slurred speech. It was very subtle, and they attributed it to being tired. Two weeks later, Laney suddenly experienced slurred speech, one side of her face was drooping as well as her mouth, she had trouble walking and using her limbs, and she complained that her hand hurt. Knowing something was terribly wrong, her parents called 9-1-1. The medics arrived at the house, assessed Laney and suggested that she be taken to the ED. The doctors suspected Laney was having seizures, and requested she be transported to another hospital for an overnight EEG. The results of the EEG showed “seizure-like” activity and the doctors suggested she would need an MRI for better assessment. Since this was a Sunday morning and there was no sedation staff over the weekend, Laney’s parents were given the choice of keeping her in the hospital until Monday or taking her home and scheduling the MRI soon. They chose to take her home. There was no mention of stroke during either of these hospital visits.

Three days later, while at home, Laney experienced the same symptoms – slurred speech, drooping mouth, trouble walking -- but more severe. Her father took a video of what they were seeing. Her parents then transported her to a different hospital ED for assessment. They showed the doctors and even a neurologist the video. A CT scan was done, and the results were normal. Again, the doctors at this third hospital diagnosed her symptoms as stemming from seizures and sent her home with a prescription for Trileptal which she took that evening. There was no mention of stroke.

A week later, Laney had her first neurology appointment and her parents were told to keep her on the Trileptal. The neurologist told them they could wait three months for the MRI to give Laney a break from all she had been through. Unfortunately, Laney developed an allergic reaction to the Trileptal—her face swelled, her body was covered in a rash and she had a high fever.

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The next day, now almost a month since Laney had experienced her initial mild symptoms, she woke up and she was unable to stand, speak, eat or drink. Her rash, fever and swelling were still present, but less severe.

For a second time, her parents called 9-1-1. The medics arrived and did not consider stroke, instead they administered epinephrine. Once she got to the hospital, she continued to have “seizure-like” episodes and was unable to stand or speak. Finally, the decision was made to transfer Laney to a larger hospital that could do more testing.

Laney was transported to now her fourth hospital, where the doctors still did not think stroke. Instead they noticed her blood pressure was high, so they gave her blood pressure reducing meds. Laney was given another overnight EEG, but she was unable to undergo an MRI because once again, this happened on a weekend and there was no sedation staff available.

Finally, on Monday, June 6, 2016, Laney underwent an MRI where it was determined that she had suffered multiple strokes over the past month. During the next 9 1/2 months, Laney struggled valiantly to regain some of her lost function, but she suffered more strokes and had two brain surgeries. Lelaina Jaymes Fitzsimons finally succumbed to the toll her strokes took on her tiny body and passed away on March 27, 2017.

Laney’s heartbreaking story epitomizes the consequences of the gap that exists in recognizing and treating acute strokes in children. Unfortunately, not only are strokes in children and teens being missed, but we don’t have established guidelines for treating strokes in children. Treatments such as clot retrieval devices and tPA have not been researched for efficacy in pediatrics. I am hopeful that moving forward, we can address these critical gaps through the development of the pediatric research agenda so that children like Laney can receive rapid diagnosis and treatment.

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Paula Denslow is the mother of two sons, Troy and Andy, that both suffered traumatic brain injuries (TBI) as children. Paula has dedicated her time to advocating for patients of TBI and their families in order to improve care for children.

Paula’s Story I am a mom of two children who had concussions and contusions, and later learned about traumatic brain injuries. Thank you for the chance to share a few lessons and questions that came along the way. Experiences and interactions, I recall as if it were yesterday. The EMS providers were confident in their skills, gentle with educating me on the injury, and gave me a sense of calm within the chaos. We learned about these types of injuries and credit Troy’s success on his determined spirit, our doctor/ medical team, family and friends, and a few school professionals. We had many trips in and out of an emergency department (ED) before and after these three times for Troy and his brother. Each experience was different. After my son Andy was injured, it never occurred to me that Andy had a sustained a brain injury in the car wreck.

Although he is doing better now, as a mom I struggle with the questions: what if we knew sooner that he had an injury that might cause changes in his personality, thinking or…

Together, how can we add to the knowledge of our healthcare providers? What tools can we make available to all emergency departments, pre-service providers and parents? What are the tools? Staff education, protocols, patient & family education, communication among hospital, family and school? That is why I am here. Here is our story.

Troy Denslow: 3 ED visits within weeks of each other – all head injuries.

In early October of 1996, at the age of 14, Troy sustained a concussion/traumatic brain injury after being assaulted from behind by a student while at school. After being hit on the back of his head, minutes later Troy was shoved, and his head hit the wall, a desk, and then the floor, leaving him unconscious for about 5 minutes and exhibiting seizure activity.

Soon, 911 was called, and they were already on the scene when I arrived at his school. The EMS team clearly stated that any one of the injuries he sustained could have killed him. I was made very aware of how significant the injury was. Troy was transported to the ED where he and I were brought together. From the time he was loaded into the ambulance, my questions began to come to mind. How did this happen? Why did it happen? Why was he riding in the ambulance without anyone he knew? What was his school doing for him… and me?

He had a CT scan in the ED. Along with the bump on his head, I understood that there were contusions on his brain. Troy spent the night in the hospital to keep a close eye on him, especially because of the reported seizure activity. He was released in the morning and we were told that he will be fine, he could return to school and we were encouraged to follow up with our family doctor.

Troy returned to school the next day without restrictions. Although he was tired and had a headache, he looked fine and wanted to get back to school. Most days Troy came home from school and went straight to bed. He would wake up to eat then sleep. We began noticing his use of the wrong word for something. His eyes were not in sync – they were dilated differently from time to time. It was easy to keep him quiet because he wanted to sleep; we thought this was part of the healing process.

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Troy was seen by our family doctor who immediately began to educate us about the injury. After two weeks, Troy was not able to join most of the activities he once did because significant headaches controlled his day and he was tired. At the end of that month, I received another call from the school. This time, a pumpkin was being tossed around the classroom. It was deflected off of a hand but landed on the top of Troy’s head.

Troy’s friends took him to the nurse. He was again seen in the ED. Once more, while sitting with friends, he took an accidental elbow to the face; this was the third trip to the ED within a few weeks of each other.

By mid-November, Troy was on a reduced school schedule which led to being totally out of school for a couple of months. Cognitive and physical fatigue paired with headaches limited his ability to attend school full-time.

In February of 1997, he began gradually to return to school. Troy did not return to a full academic schedule until 4 ½ years later which was the last marking period of his senior year in high school, and then he was only present for 2 days out of a 6-day cycle.

In June of 2000, Troy graduated from high school on time along with his peers; two weeks later he was off to college and literally hasn’t been home since, except to visit. He is happily married, a proud daddy and is working in his chosen field – the golf industry.

Andy Denslow: In 2002, at the age of 17 and about to enter his senior year in high school, Andy sustained a traumatic brain injury following a motor vehicle collision while driving on an Interstate during a summer afternoon thunderstorm. Andy was seen in the ED with notes that he would be sore and have a headache. As the days went by, bruising was noticed on his chin from what we think was where the steering wheel hit him and the seatbelt strap across his chest. They were right, he definitely was sore and had a headache. Small changes were noticed by my husband and I that were not a big deal at the time. Over time, and when we looked at the big picture, we noticed the changes were increasing and we thought it to “senioritis.” Approximately 6 months after the car accident, we struggled to find the Andy we knew and didn’t understand or like the person he was becoming. He declined academically, his friendships were different. We didn’t know his new friends. Sleep changes and behavioral and cognitive changes continued over the years. As a family, we held strong and at any teachable moment, we tried to help Andy understand TBI. In 2013, after multiple life events, Andy began to regain his life, one layer at a time. Today Andy is enjoying a successful career as a heating/ventilation/air condition technician, is close with his family and looks forward to the next chapter in his life.

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Troy’s Story My first emergency department visit occurred during a sixth-grade field trip to Washington DC, when I was about 12 years old. I began feeling nauseous and dizzy as we stepped off the bus at the Capitol Building.

Medical staff on site took me by ambulance to the local Children’s Hospital where I went through a series of examinations to figure out what was causing my symptoms.

I remember one particular examination, quite vividly, to this day. The emergency doctor, who made multiple comments throughout the day Troy Denslow is a survivor of pediatric traumatic about needing to get to a concert, performed a rectal examination far too brain injury. He is a husband and proud father and is aggressively and with a lack of compassion given the situation. Very little the eldest son of Paula Denslow. was discussed ahead of time so even at a young age, I recall feeling confused, scared, and angry at how he conducted the exam so inappropriately. I cried so hard that my voice fell silent. My parents were at the head of the bed holding my hand which provided some form of comfort. It all happened so fast but immediately following the examination, I was proud of my parents for taking action.

They demanded the emergency doctors and directors to discuss what just happened as well as the actions of the doctor who performed the exam. The whole situation was confusing and troubling. I’m sure the medical team discussed it ahead of time with my parents but it was still alarming as a patient along with the lack of compassion used.

The doctors and my parents came in together and explained they were looking for potential blockage that could be causing the stomach pain. I remember the nurses were wonderful and very sympathetic, bringing blankets and constantly asking if I needed anything to be more comfortable. Without their bedside manner, I may have lost all faith in the process and would have taken years to rebuild that trust.

As a parent of two under the age of 6 and having taking them to the ER on multiple occasions, I often reflect on that experience and pay close attention to the care provided from start to finish. I make sure to ask lots of questions ahead of time and include my children whenever appropriate. The Child Care Specialists in the top hospitals make an amazing difference but anytime they’re not present or even an option, my wife and I take over that role to ensure a proper experience.

My second ED visit occurred In October of 1996, at the age of 14, when I was assaulted by another student at school from behind and sustained a concussion/traumatic brain injury. Moments later, I was thrown head first into the wall where I must have lost consciousness while my head hit the desk and floor on my way down.

Students reported seizure like activity for a few minutes following the assault. I recall waking up on the floor and feeling confused as a teacher and student helped me into a wheelchair without any head support. They rushed me to the nurse’s office where EMT personnel met us. They offered a very calming presence as I began to wonder what happened, why did it happen, where was the teacher, where were my friends? As they continued the examination, I heard my mom’s voice in the room which made me feel even safer.

I was transported to the local ED by ambulance where my mom and I reconnected. The entire time, and I imagine due to effects from the concussion, I simply felt confused. What was happening to me, what was going to happen, was there something wrong with my eyes which caused the need for the flashlights, etc.?

The EMTs were very warm in their approach and I thank them for that, but they also moved with a sense of urgency which added some anxiety to the situation. In hindsight, I know they were doing their job to prioritize my health and safety knowing there would always be time for explanation later.

The ED I was transported to was not a teaching hospital but still had a great reputation in the area. In the ED, I received a CT scan. Funny to think I still remember the doctors name. She explained a lot to me including 16

small contusions on my brain. I spent the night in the hospital, still very anxious about what happened, and what was going to happen, at school, to the other student, whether I’d play in that weekends soccer game.

Sounds like the seizure activity was concerning, along with the head injury, so I was woken up multiple times throughout the night before finally being released the next morning. While in the ED for 6-8 hours, I was seen by two physicians and a number of nurses, techs, etc. After transferring me upstairs to be admitted, I met with another physician and our primary care provider.

I returned to school within a few days and received a warm welcome. I felt safer knowing the other student was no longer allowed at school but also knew I’d see many of his friends. Thankfully my parents, teachers, counselors, and even my friends were very supportive as I slowly regained my confidence. Over the next few weeks, I found myself feeling extremely lethargic. So much that I was pulled out of school and received my education at home from tutors. Over the next few months, I went back to school for one class at a time. At the start of my sophomore year, I was in school for five classes (8:00 am - 12:30 pm) until the last semester of my senior year. I’m proud to say I graduated on time, with honors, and went on to college and my dream career in the golf industry.

The road to recovery lasted many years throughout my life, and the lives of those I loved around me, was forever changed. I truly believe my experience in the ED, as well my family’s experience, created the foundation for what eventually became a positive outcome.

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Kim’s Story I am a mom to two boys: Jackson who is 23 and our youngest, Carter, would be 11 but he passed away when he was 9. My oldest son was always getting injured, and we spent a bunch of time in emergency rooms and they were all non-pediatric emergency rooms.

When our youngest was born, I thought I was an experienced mom and ready for what life with two children would throw at me. However, Carter was sick from the beginning.

He had feeding issues, and growing issues, and at 5 weeks old he was diagnosed with a heart murmur. Luckily, there were no further complications with that. Then at 6 weeks old, he was a direct admit to our local pediatric hospital for failure to thrive and was diagnosed with oral motor feeding disorder. He was born at 6 pounds 10 ounces, and at 6 weeks old, he was only 6 pounds.

Kim Mears is a mother of two boys, Jackson and Carter. Carter struggled with many illnesses as a child, and at the age of 9 passed away. Kim hopes that sharing Carter’s story will inspire healthcare providers to find ways to reduce the gaps in pediatric care

Carter continued to have GI issues, and at 2 ½ years old, he was diagnosed with Crohn’s Disease. He spent quite a bit of time in the pediatric ER as well as being hospitalized there. When Carter was 7 years old, he was bitten by a dog and then suffered a flare from his Crohn’s disease that lasted over 3 months. He spent most of that time in the hospital. He lost 10 pounds, stopped eating and drinking and also stopped talking. It was very hard for doctors to understand what was going on, so finally he was transferred to a bigger children’s hospital. He was then diagnosed with Pediatric Neuro Behcet’s Disease. Life became even harder for him and our family. The brain inflammation changed him as a person and it was very hard to see him act so out of character.

Over the next year or so, he went in and out of the ER and hospital. In February 2015, while Carter was in inpatient care, he perforated his bowel and never walked again due to his back fractures. He spent 56 days in the PICU before being discharged on hospice.

Over the next 6 months, Carter had to be taken to a local hospital because he became unresponsive after the ambulance arrived at our house. I knew non-pediatric hospitals were different but never that different. Most of his set protocols for his medical care could not, or were not, followed. He had to be bagged for 1 ½ hours due to not being able to be intubated. A rectal temperature was taken which showed a fever, but he did not get the antibiotics that he needed until the LifeLine helicopter arrived.

Carter taught us so much about life and medicine. I hope I am able to help others with his story.

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Breakout Themes Pediatric EMS Research Goal: To create a research agenda for the pediatric EMS research community that will advance the science of EMS for children and ultimately improve patient outcomes.

Objectives: 1. To explore research opportunities to determine whether established best practice for pediatric EMS care improves patient oriented outcomes 2. To discuss the best methods to study challenging but high impact clinical conditions such as out-ofhospital cardiac arrest, drowning, severe trauma, and respiratory failure 3. To identify opportunities to translate knowledge and evidence into the prehospital setting Background: Currently there is a need to create a research agenda for pediatric EMS. Previous reports have identified potential research priorities beginning with an Institute of Medicine report in 2006.1-2 However, to date there has been relatively little research in EMS for children and in many areas the science is immature.

There have been only been two randomized trials conducted to date, which investigated airway management and seizure treatment.3-4 Other investigators have begun to define safety events and explore the frequency and root causes of medication errors pediatric EMS care.5,6 Finally, there is a concerted effort among national organizations and researchers to focus on defining and implementing “best practices” in pediatric EMS care derived from the currently available evidence base which is generally recognized to be limited. Other important priorities include learning how to efficiently translate the growing evidence base into practice and identifying the potential impact of established “best practices.”

Compared to previous reports that relied on relatively focused groups of experts, this consensus conference offers an opportunity to convene a broad audience of stakeholders to discuss scientific priorities with the potential to generate new ideas and engage new investigators. Creation of a research agenda can also focus efforts of the small but growing group of pediatric EMS investigators on specific topics that will allow us to collectively advance the science of EMS for children and improve patient outcomes.

References: 1.

Institute of Medicine, System. Emergency care for children: growing pains. Washington, DC: National Academies Press; 2006.

2.

Institute of Medicine. Emergency Medical Services: At the Crossroads. Washington, D.C.: The National Academies Press; 2006.

3.

Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283(6):783-790.

4.

Silbergleit R, Lowenstein D, Durkalski V, Conwit R, Neurological Emergency Treatment Trials I. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8:45-47.

5.

Lammers R, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency.

Academic Emergency Medicine. 2012;19(1):37-47.

6.

Hoyle Jr JD, Davis AT, Putman KK, Trytko JA, Fales WD. Medication dosing errors in pediatric patients treated by emergency medical services. Prehospital Emergency Care. 2011;16(1):59-66.

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Pediatric Emergency Medicine Research Networks Goals: • To increase attendee understanding of, participation in, and prioritization of pediatric emergency medicine network research • To demonstrate how pediatric emergency medicine network research results can improve care of acutely ill and injured children Objectives: • To identify priorities for future pediatric emergency medicine network research • To provide conference participants an opportunity to brainstorm and discuss potential future network research studies Background: Despite the inherent differences between pediatric and adult emergencies, pediatric patients have at times been considered and treated as small adults. In general, when compared to research in adult emergencies, research in pediatric emergencies is often limited by inadequately powered studies, especially in conditions that are of low frequency. An important reason historically has been a lack of a robust research infrastructure to conduct studies to evaluate pediatric emergencies. Other pediatric subspecialties have addressed this issue by forming research networks. Two good examples include The Children’s Oncology Group (COG) and the Neonatal Research Network. Similar efforts in in pediatric emergency medicine over the past two decades, however, have helped close that gap in the United States. The American Academy of Pediatrics (AAP) Section on Emergency Medicine’s PEM Collaborative Research Committee (PEM-CRC), which was followed by a federally supported multicenter research network called the Pediatric Emergency Care Applied Research Network (PECARN) have made great strides in addressing important pediatric emergency research issues.

Currently, several similar PEM research networks exist worldwide. The drivers for the creation of these networks has been to both investigate high frequency but understudied diseases (to address generalizability issues), as well as low frequency but high stakes illnesses (to address issues related to under-powered studies).

One example of the latter is the study of therapeutic hypothermia in pediatric cardiac arrest. An example of the former is the study of suicide screening in large numbers of geographically or ethnically diverse populations in a cost-efficient manner. Now that we have PEM networks that are mature, it is important to focus on leveraging individual network strengths to align and generate a common agenda. Such strategic alignment will allow the PEM networks to continue to address issues related to the acutely ill and injured child in a more coordinated fashion, to translate research into practice and then to inform the policy agenda.

Additional benefits include the training of next generation of pediatric acute care researchers, attracting extramural federal and other (foundation, pharma, philanthropy) funding to sustain research for this most vulnerable population during their most critical time of need.

References: 1.

2.

3.

Deane, H.C., et al., PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand. Emerg Med J, 2018. 35(1): p. 39-45.

Hartshorn, S., et al., Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland. Emerg Med J, 2015. 32(11): p. 864-8.

Miller, S.Z., et al., Revisiting the emergency medicine services for children research agenda: priorities for multicenter research in pediatric emergency care. Acad Emerg Med, 2008. 15(4): p. 377-83.

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Pediatric Emergency Medicine Education Goal: To introduce a research agenda that can unify and advance pediatric emergency medicine education, promote a network for ongoing progress, and improve outcomes for acutely ill and injured children.

Objectives: 1. Identify fundamental research priorities to close the many education gaps that underlie non-uniform care for children across emergency departments and urgent care centers in the US. 2. Propose key steps to launch a PEM education research network.

3. Discuss how information from the patient experience may be integrated into PEM education research.

Background: Education is in many ways the cornerstone of pediatric emergency care, as learning and practice are inextricably linked together. There has indeed been progress. What was a once novel teaching concept that “children are not small adults” is now widely accepted, and a clear imperative now exists for core and ongoing training in pediatric emergencies across the spectrum of health providers. The evolution of certificate courses such as PALS, NALS, and APLS introduced important building blocks for the early recognition and response to emergencies in children. These have had a positive impact on outcomes for pediatric patients yet fall short of what is needed overall. An array of education research continues to reshape the possibilities for simulation, ultrasound, online learning, and other areas that can advance pediatric emergency care. The next phase of progress in PEM education hinges on consensus in training goals and methods to achieve these goals, for which outcomes-based education research can play a pivotal role. Our central thesis is that the gaps in PEM education are a critical factor in non-uniform care for children across emergency departments and urgent care centers in the US. References:

1. Cloutier RL, Walthall JDH, Mull CC, Nypaver MM, Baren JM. Best Educational Practices in Pediatric Emergency Medicine During Emergency Medicine Residency Training: Guiding Principles and Expert Recommendations.

Academic Emergency Medicine. 2010;17(Suppl 2):S104-S113.

2. Woods R, Chan T, Thoma B, Sherbino J. Education scholarship in Canadian emergency medicine: The past, present, and future. Canadian Journal of Emergency Medicine. 2018; 20(2): 164-66.

3. Newgard CD, Beeson MS, Kessler CS, et. al. Establishing an Emergency Medicine Education Research Network.

Academic Emergency Medicine. 2012; 19:1468–1475.

4. Porath JD, Meka AP, Morrow C, Iyengar R, Shtull-Leber E, Fagerlin A, Meurer WJ. Patient preferences for diagnostic testing in the emergency department: a cross-sectional study. Academic Emergency Medicine. 2018; 5.

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Workforce Development for Pediatric Emergency Medicine Goal: To delineate and prioritize a research agenda to advance our understanding of the unique workforce needs in the emergency care of children in the interest of ensuring excellence in pediatric care and improve patient outcomes across emergency care settings.

Objectives: 1. To define highest-priority areas of research and workforce needs in pediatric emergency care 2. To engage a group of stakeholders in a discussion of means and targets for workforce research in pediatric emergency care 3. To identify opportunities to translate workforce knowledge and evidence into the array of pediatric care environments Background: A decade ago, the Institute of Medicine (IOM) expressed “continued concerns about the ability of the emergency care workforce to care properly for pediatric patients.�1 Among these concerns included uneven training and continuing education of emergency care providers in pediatric emergency care competencies, inadequate development and distribution of clinical practice guidelines and care standards for emergency care of children, and the importance of local pediatric emergency readiness and coordination.

While the decade since publication of this report has undoubtedly yielded improvements, the professionals who provide emergency care for children - from prehospital providers to nurses, technicians, pharmacists, social workers, nurse practitioners, physician assistants, and physicians from many specialties - continue to face increasing demand with uneven capacity. Each year, more than 30 million children are seen in emergency departments in the US, and the vast majority of these children are cared for in general emergency departments outside of children’s hospitals.

The diverse workforce of care providers must possess the knowledge, skills and systemic support necessary to deliver excellent pediatric emergency care. New advances in pediatric care, safety and skills require ongoing education and coordination across a diversity of providers. Stressors such as boarding and psychiatric emergencies mandate the ability for the workforce to flex and contract based on a multitude of scenarios.

There is a crucial need to understand the factors that drive the professional development and support systems of this workforce. A robust research agenda must be developed to inform the ongoing investigation into understanding the factors driving the development and maintenance of the pediatric emergency care workforce. Through the iterative process at the 2018 Academic Emergency Medicine consensus conference, we will identify key research themes and prioritize specific research questions. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce, and will allow a prioritization of future research efforts.

References:

1. Institute of Medicine, System. Emergency care for children: growing pains. Washington, DC: National Academies Press; 2006.

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Pediatric Emergency Medicine in Non-Children’s Hospitals Goals: To include general EDs based in non-children’s hospitals in creating a research agenda to advance the quality and safety of pediatric emergency care across all EDs, understand the challenges, and enhance the collaboration with children’s hospitals to achieve optimal health outcomes.

Objectives: 1) Create best practices for developing a system of care for general EDs and those in children’s hospitals to collaborate and focus on solutions to close the gap on safety, quality, and evidence-based practice in a patient/family-centered setting. This system should meet the needs of both groups to provide the best clinical care for pediatric patients.

2) Develop pediatric specific outcome measures and implementation processes to ensure continuous quality improvement.

3) Evaluate the National Pediatric Readiness Project (NPRP) initiative, a quality improvement project designed to promote the optimal care of children in EDs, and its effect on patient outcomes.

Background: Health emergencies occur in all age groups leading to visits to the Emergency Department (ED).

The most recent ED volume statistics published in 2014 by the CDC report about 141 million ED visits in the United States. Of those, approximately 27 million visits were for children under age 15 (20% of all ED visits). 1 The EDs vary in their pediatric patient volume, and most EDs are general EDs in non-children’s hospitals, providing care to patients of all ages. The fact that the majority of patients seen in these EDs are adult patients, the EDs have not focused on children, posing a major challenge to readiness for pediatric visits to the ED, ranging from simple to the most complex clinical presentation. Two recent studies 2,3 describe national pediatric ED visits with respect to each ED’s annual pediatric patient volume: 39.3% were low-volume EDs (fewer than 1,800 pediatric visits per year, or fewer than 5 children per day) evaluating 5% of the overall pediatric visits; 30% were medium-volume EDs (1,800 to 4,999 pediatric visits per year, or fewer than 14 children per day) evaluating 18% of overall pediatric visits; 17% were medium-to-high volume EDs (5,000 to 9,999 pediatric visits per year, or fewer than 28 children per day) evaluating 24% of the overall pediatric visits; and 13.7% of EDs were high volume (10,000 or more pediatric visits per year, or >/= 28 children per day), evaluating 53% of the overall pediatric visits. Overall 85% of pediatric ED Visits are to general EDs. 2 A major barrier for EDs to improve pediatric quality of care is that 86.3% of EDs see fewer than 28 children per day 2, yet evaluate approximately 47% of the overall pediatric visits. 3 Not surprisingly, it has been shown that pediatric readiness correlates with pediatric visit volume, with weighed pediatric readiness score (WPRS) increasing from a median of 68.9 for low volume EDs to 89.8 for high volume EDs.2 Unique challenges are faced by the EDs in that they must focus on pediatric quality concurrent with working on many competing demands for their adult population of patients. This consensus conference offers a unique opportunity to create a research agenda that facilitates partnering of the diverse stakeholders in developing a system of care across all ED settings with quality and safe care for all children.

References:

1. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. Available from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2015_ed_web_tables.pdf.

2. Gausche-Hill M, Ely M, Schmuhl P, Telford R, Remick KE, Edgerton EA, Olson LM. A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatr. 2015; 169(6):527–534. doi:10.1001/jamapediatrics.2015.138 3. Whitfill T, Auerbach M, Scherzer D, Shi J, Xiang H, Stanley R. Emergency Care for Children in the U.S.: Epidemiology and Trends Over Time. Journal of Emergency Medicine. 2018; Accepted April 15 pending publication 23

ORGANIZING COMMITTEE Kathleen Adelgais, MD, MPH is an Associate Professor of Pediatrics at the University of Colorado School of Medicine and a Pediatric Emergency Medicine physician at Children’s Hospital Colorado in Aurora, CO. She serves as the Principal Investigator and Program Director for the Colorado EMS for Children State Partnership program, is the past-chair of the Pediatrics Committee for National Association EMS Physicians, and previously represented the American Academy of Pediatrics on the board of directors for Committee on the Accreditation EMS Programs. She also serves as the scientific advisor for the Aurora Fire Department EMS affiliate role in PEM-NEWS node within the Pediatric Emergency Care Applied Research Network (PECARN).

Isabel Barata, MS, MD, MBA is Associate Professor of Pediatrics and Emergency Medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Barata is the Pediatric Emergency Medicine Service Line Quality Director for Northwell Health System, a joint Emergency Medicine and Pediatrics Service Line position. She also serves as Director of Pediatric Emergency Medicine at North Shore University Hospital. Her current role is to enhance the day-to-day pediatric readiness of emergency departments (EDs) across the Northwell Health System, improve pediatric patient safety in the ED, elevate the needs of children to the healthcare system level, and foster the relationships among the emergency departments and the children’s hospital.

Jean Klig, MD is an Assistant Professor of Emergency Medicine and Pediatrics at Harvard Medical School. She is also an attending physician and the Associate Chief in the Division of Pediatric Emergency Medicine at the Massachusetts General Hospital.

Dr. Klig leads program initiatives in PEM at the undergraduate and graduate levels. She has served on the faculty of the Harvard-Macy Institute’s “Program for Educators in the Health Professions” for many years. Dr. Klig completed her residency in Pediatrics at Children's Hospital, Boston MA, and her fellowship in Pediatric Emergency Medicine at Children's Hospital Oakland, CA. Academic interests include building critical thinking skills in pediatric emergency medicine, and faculty development in the assessment of clinical performance.

Maybelle Kou, MD has directed the Altieri Pediatric Emergency Medicine Fellowship at Inova Fairfax Medical Campus since 2001. She is a member of the AAP SOEM Fellow Directors Committee and the ACEP Pediatric Section. As one of few Emergency Medicine trained physicians on this committee, she was a team lead in the planning and execution of the ACGME subspecialty milestones for Pediatric Emergency Medicine, and later the EPAs. Dr. Kou is a member of the International Network for Simulation-based Pediatric Innovation, Research and Education. Her research interests include simulation to teach team training, procedural competency, non-technical skills and debriefing. She is completing a Masters degree in Education and Human Development with a focus on resuscitation leadership. She has additional interests in pediatric resuscitation, educational technology and advocacy.

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Chris Merritt, MD, MPH is an Assistant Professor of Emergency Medicine and Pediatrics at the Alpert Medical School of Brown University and a Pediatric Emergency Medicine physician at the Hasbro Children’s Hospital in Providence, RI, where he currently serves as the interim program director for the pediatrics residency. Dr. Merritt’s academic and research focus is in medical education, and he is completing a master’s degree in health professions education (MHPE). He has served on the editorial board of the Emergency Medicine section of the Pediatrics Review and Education Program (PREP E*Med) for the American Academy of Pediatrics.

Michael Stoner, MD is Assistant Professor of Pediatrics at the Ohio State University College of Medicine, an attending Pediatric Emergency Medicine physician. He is also associate medical director of the critical care transport team at Nationwide Children’s Hospital in Columbus OH and the pediatric medical director for Metropolitan Emergency Consortium, an EMS agency serving the greater Columbus area. He is board certified in Pediatric Emergency Medicine and has practiced PEM at Nationwide Children’s hospital since 2006 following fellowship at the same facility. Dr. Stoner serves as a member of the American College of Emergency Physicians (ACEP) Pediatric Emergency Medicine Committee as well as the AAP Pediatric Education for Prehospital Professionals (PEPP) Steering Committee. His scholarly activities include medical education and simulation. He is also site PI for the Pediatric Emergency Care Applied Research Network (PECARN) FLUID study. Other scholarly interest includes prehospital care, asthma and pediatric analgesia procedural sedation.

Prashant Mahajan, MD, MPH, MBA is the Vice-Chair, Department of Emergency Medicine at University of Michigan, Ann Arbor, MI. He also serves as the Section Chief of Children’s Emergency Services at C. S. Mott Children’s Hospital, Ann Arbor, MI. He is a tenured Professor of Emergency Medicine and Pediatrics. He serves as the Chair, Section of Emergency Medicine for the American Academy of Pediatrics (AAP). He completed his PEM fellowship in 2002 and received his MPH in Health Management and Policy and an MBA in healthcare. Dr. Mahajan is a pediatric health services and outcomes researcher. His research interests include infectious diseases (evaluation and management of febrile infants) including development of clinically meaningful decision rules in the evaluation of febrile infants, inflammation (asthma, sepsis) as well as clinical decision making in a cognitively dense acute care setting.

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Conference Chairs

ACKNOWLEDGEMENTS Seth Linakis, MD – Scribe Lise Nigrovic, MD MPH Damian Roland, BMedSci BMBS MRCPCH PhD

Paul Ishimine, MD Kurt Denninghoff, MD

Keynote Speakers

Education Jean Klig, MD Maybelle Kou, MD Rahul Bhat, MD Andrea Fang, MD Sean Fox, MD Jeffrey Hom, MD Ashley Strobel, DO Sonny Tat, MD Jessica Wall, MD Eric Weinberg, MD

Terry Klassen, MD, MSc, FRCPC Nathan Kuppermann, MD, MPH

Patient Advocates Mary Kay Ballasiotes Paula Denslow Troy Denslow Kim Mears Parris Shelley

Committee Members:

Workforce Chris Merritt, MD, MPH Christopher Amato, MD Amanda Bogie, MD Ann Dietrich, MD Michael Gerardi, MD Kajal Khanna, MD, JD Alfred Sacchetti, MD Mohsen Saidinejad, MD, MPH, MBA Fred Wu, MD

EMS Kathleen Adelgais, MD, MPH Kathleen Brown, MD J. Joelle Donofrio, DO Matt Hansen, MD MSCR E. Brooke Lerner, PhD Non-Children’s Hospitals Isabel Barata, MS, MD, MBA Marc Auerbach, MD Oluwakemi Badaki-Makun, MD Lee Benjamin, MD Madeline Joseph, MD Moon Lee, MD Emory Petrack, MD Dina Wallin, MD

Scribes Isabelle Chea Ryan Hartman, MD Seth Linakis, MD Teresa Liu, MD Nadira Ramkhelawan, MD

Research Networks Michael Stoner, MD Prashant Mahajan, MD, MPH, MBA Jill Baren, MD, MBE Silvia Bressan, MD, Ph.D Corrie Chumpitazi, MD, MS Stephen Freedman, MDCM, MSc. Aaron Kornblith, MD Nathan Kuppermann, MD, MPH Sam Lam, MD, MPH

Society for Academic Emergency Medicine & AEM Jeffrey A. Kline, MD, AEM Editor-in-Chief Rakesh Mistry, MD, MS, AEM Decision Editor Robert Cloutier, MD, MCR, AEM Decision Editor Stacey Roseen, SAEM/AEM Holly Byrd-Duncan, MBA, SAEM Melissa McMillian, CNP, SAEM

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