Designing a pediatric emergency triage and action program

BACKGROUND In Japan, non-pediatricians face many instances in which they must see children, partly due to the uneven distribution of pediatricians among urban and rural areas. We aimed to develop and examine the effect of a model simulation-based training program in pediatric primary care for non-pediatric medical and ancillary personnel who express misgivings about seeing pediatric patients in an emergency setting due to their perception of their lack of training in this area.METHODS We instituted a series of workshops on common pediatric emergency situations, first with physicians, and later also including ancillary personnel, as a form of interprofessional education. The entire program was constructed around Design-based Research.RESULTS Feedback from attendees and facilitators was mostly positive, leading us to open the workshops to ancillary personnel.CONCLUSIONS From a training point of view, this epistemological investigation was successful in mitigating anxieties in individuals about seeing pediatric emergency patients. The effects on patient care remain to be studied.

Abstract BACKGROUND In Japan, non-pediatricians face many instances in which they must see children, partly due to the uneven distribution of pediatricians among urban and rural areas. We aimed to develop and examine the effect of a model simulation-based training program in pediatric primary care for non-pediatric medical and ancillary personnel who express misgivings about seeing pediatric patients in an emergency setting due to their perception of their lack of training in this area. METHODS

Background
The Swedish physician Nils Rosen von Rosenstein founded modern pediatrics as a medical specialty in the 18 th century, independent from internal medicine. 1 Developments in pediatric research have led to advances in pediatric care and, from the perspective of medical education, have led to the creation of pediatrician training programs. 2 As medicine and medical training become more specialized, each specialist is exposed less and less to other medical specialties. Recently, physicians other than pediatricians have become hesitant to examine children, particularly in developed countries, where lawsuits for medical errors are common. 3 In Japan, unlike other developed countries, non-pediatricians face many instances in which they must see children. This is partly because of the uneven distribution of pediatricians among urban and rural areas. 4 Formal training programs for general practitioners (GPs) working in pediatric primary care settings were not available before the Japanese Primary Care Association began to establish pediatric training sites in 2009. 5 Currently, a relatively large number of physicians-especially physicians in rural areashave no choice but to see children despite having no pediatric training after completing their initial postgraduate training program. 6 This indicates the need for systematic training for nonpediatricians who are required to see children in primary care settings. We hypothesized that, if simulation training programs could standardize pediatric clinical practices by nonpediatricians, it would improve the quality of care and help solve the disparities between the pediatric healthcare available in urban versus rural areas. We therefore aimed to develop a model simulation-based training program in pediatric primary care for nonpediatricians.
Here, we describe the process and outcome of designing a simulation training program using a Design-based Research (DBR) approach, design science 7 as an epistemology, and the conceptual framework of "mastery learning." [8][9][10] Methods

Context
In Japan, physicians who are not pediatric specialists are often required to examine children. For example, according to a report by Kuwahara, 11 58% of non-pediatricians actually examine children. There are three reasons for this. First, pediatricians in Japan suffer from exhaustion; there is an average of 3.8 pediatricians per hospital in Japan, 12,13 which is lower in comparison to other countries. 14,15 Second, since the education system for GPs in Japan was established later than in other countries, non-pediatricians previously had to provide primary care to children. Recently, the "general practitioner" system was listed as the 19 th basic medical specialty in Japan (a "primary care" system was previously in place, but was not considered one of the approved medical specialties), which leads to the expectation that general practitioners will be closely involved in the care of children.
Lastly, Japan has a system in which local municipalities supplement part or all of the cost of pediatric examination and treatment at medical facilities. Thus, the cost of pediatric medical care is extremely low, and in some communities is even free. Many physicians who are involved in after-hours primary medical care are family physicians or emergency physicians rather than pediatricians. Thus, there are occasions in which physicians who are not specialists in pediatrics provide after-hours medical care to children.

Design-based Research
We adopted DBR as the methodology for this study of theory-led development of the Pediatric Emergency Triage and Action Program (PETAP). DBR is a methodology of educational research that takes place in actual educational settings. 16 It approaches complex problems about learning phenomena in a real learning cotext. 7 One of the characteristics of DBR is that it is conducted in continuous cycles of design, enactment, analysis, and redesign, always with the goal of improving educational practice. 17 A second important characteristic is that the design of the learning environment is based on theoretical principles, aimed at advancing theories. 18 Thus, it is argued that DBR could help to bridge the gap between research and practice in medical education. 16

Phase 1: Designing the initial version of PETAP
In 2009, we developed and implemented the first version of PETAP for residents in the emergency medicine rotation in Iizuka Hospital (Table 1). PETAP is a 6.5-hour, case-based, off-the-job simulation training program dealing with the initial assessment of pediatric patients by a health care provider.

Phase 2: Enactment and analysis
As we attained a high level of satisfaction from the participants, we continued to conduct the program while making minor revisions. We began holding workshops as part of the lifelong learning programs of several medical associations in 2010, and then expanded the program to several facilities. By the end of 2013, we had implemented the program 40 times for 933 participants in total. In 2014, we selected the location of future workshops from among requesting regions without bias with regard to region or to urban or rural area. To analyze the initial version of the PETAP from the perspective of medical education principles and theories, we conducted two focus groups for ten facilitators of our program in January and eight in June in 2014. The focus groups, which reviewed PETAP up to 2013, were subject to purposive sampling by members, including the authors, who participated as facilitators at least twice between 2009 and 2013.
Program data were evaluated by the first author (TM) using the thematic analysis method.
HN discussed the identified themes with TM after a separate reading of the transcripts.

Phase 3: Redesign, reenactment and reanalysis
Based on the results of the analyses, we developed the second version of the PETAP (Table 1)

Phase 4
Based on the results of the phase 3 analyses, we again revised the program and developed the third version of PETAP (Table 1)

Results
The process of developing the PETAP is described below. Specific focus group data that were used to revise the program are shown in Table 1.

Participants
As the contents of the course became known to GPs, they expressed the desire to participate, and as a result, the number of GPs attending PETAP increased. Medical students and nurses were also among the participants in Version 3.

Setting
As more and more primary care physicians participated, the training was changed to an emergency outpatient setting. As more ancillary professionals, such as nurses, began to participate, the settings became more diverse and included locations that provide health guidance and handle telephone calls.

Learning objectives
When this wide variety of medical practitioners and ancillaries began to participate, we determined that it was necessary to revise the learning objectives such as those regarding initial care in an urgent setting for each type of participant.

Learning contents
The learning contents have not been changed since the program was developed. There was debate over whether rash should also be included, but based on the current duration of the entire course, it is not currently included. We briefly considered anaphylaxis in triage.

Learning strategies
We increased the sense of reality by using photos of children's (patient's) faces on a tablet (when showing video of the sound of a child with asthma breathing and an abdominal ultrasound of intussusception of the intestine). However, some participants pointed out the limitations of photographs and videos. We also implemented methods that included multidisciplinary cooperation through the participation of nurses. One specific example of this was the use of the "Help Card" (a tool that makes it easier for nurses participating together to consult with physicians).

Assessment
Since PETAP was first developed, it has never been subject to an overall assessment. The participants conducted self-assessments based on observations of the examinations of other participants and offered feedback to each other. The creation of an overall assessment remains a task for the future.

Facilitation
We discussed how to teach just prior to the course, but as part of our revisions, we also created a teaching guide for facilitators.

Authorization
The program has expanded and is currently being conducted with the authorization of associations such as the Japan Primary Care Association and the Society of Ambulatory and General Pediatrics of Japan.
The current structure and schedule of PETAP are shown in Figures 1 and 2.

Theory testing -Standardizing practices by simulation training
Standardization of healthcare has been influenced by the format of the electronic health records used at facilities where the program has been run repeatedly. However, courses are held without much standardization, and external experts have expressed their opinion about the validity of the program. Example comments include: "The fact that there is no standardized facilitation manual is both an advantage and a disadvantage. In other well-known courses (e.g. ACLS, 19 PALS 20 ), teaching methods other than the approved methods are not allowed, and so in the course the participants learn in a standardized way. Although there was discussion, I had the impression that one of the goals was to standardize everything." (June 2014, a pediatrician in Hokkaido) "Although electronic medical records are now being used, when you type into an electronic chart, the first thing that comes up is something like a structured format in writing when you see children … and when you check that and consult with a pediatrician, it is used in the discussion, so I think it is very useful." (Jan. 2014, a pediatrician in Kyoto) "Now, even though standardization has occurred, it has not been completed. I think this amount of standardization is enough." (April 2016, a general internist in Tochigi)

Discussion
We created a pediatric emergency education program called PETAP for non-pediatricians who are involved in primary care. The current form was constructed by carrying out changes based on feedback from the participants in this study in the context of Japanese medicine and medical education.

Strengths and limitations
The major strength of this study is that in the 9 years since the program's development (2009-2017) the program has been conducted a total of 106 times and has had a total of 2413 participants. A second strength is that it can be implemented continually at low cost and without the use of expensive simulations.
In general, simulation courses are standardized so that only certified instructors provide feedback. 10 However, this type of standardization may result in a loss of diversity in the education provided. 21 This program promotes peer-assisted learning through peer feedback 22 and was intentionally designed without an excessive amount of standardization, allowing for different contexts. This is another of the program's strengths.
In Japan, which has a culture that is strongly influenced by collectivist ideas that emphasize relationships, the behavior of others has a major effect. 23 One of the strengths of this program is that, by watching other participants actually provide medical care, participants learn about pediatric care via a hidden curriculum that is independent of the contents taught in the program itself. This type of method is likely to be effective in a country with a culture that is strongly influenced by collectivist ideas.
There are reports 23-26 on the utilization of interprofessional education (IPE) using advanced cardiac life support (ACLS 19 ) and other types of simulation-based education, such as this program. The fact that this program uses IPE is one of its major strengths, particularly today, when IPE is increasingly viewed as important. 27 Analysis of the specific types of participants in the program between 2009 and 2016 indicates that 66% were physicians and 31% were nurses. In recent years, there has been an increasing trend in the number of pharmacist and paramedic participants. This program provides a forum for IPE.

Limitations
Since PETAP is conducted in a single country, its transferability to other countries may be a limitation. However, since it is not a high-cost simulation program, it can be generalized for many countries.
Since assessment of the program was carried out by a focus group using qualitative data, it is unclear whether the program participants experienced improvement in their pediatric care after undergoing training with the program. If possible, empirical research that shows, for example, improved results compared with a group of subjects who did not take the course at Level 4 of Kirckpatrick's curriculum evaluation 28 should be conducted in the future.
Another limitation of this study is that, like other simulation-based programs, the program is human resource-intensive.

Relationship to other research
The pediatric simulations PALS 20 and PEARS 29 , which were provided by the American Heart Association (AHA), are well-known. The differences between these programs and PETAP are as follows: 1. PETAP is focused on the primary care of diseases frequently encountered in primary and secondary emergency care, without specialization for cardiopulmonary resuscitation or the primary care and treatment of severe diseases such as shock; 2. it assumes primary care medical standards rather than those of emergency care centers; and 3. it discusses home care in scenarios in which patients are able to return home as well as short-term case presentations in scenarios that require referral to a pediatrician.
These three points are the major differences between this program and other programs.
The implications for medical care are as follows: in resource-poor settings with few physicians, a limited absolute number of pediatricians, and an unbalanced distribution of pediatricians throughout the regions of Japan, training opportunities in pediatric care for physicians are essential to ensure the quality of medical care. We hope that this program will be used as a pediatric simulation-based education model program in other countries with limited medical resources. We also believe that it can be used in the context of pediatric care education for all medical students, including those who are unlikely to become pediatricians after graduation (this program is already being implemented at Kyoto University). We also believe it can be utilized for the education of ancillary medical professionals, such as nurses. Given that few studies in the medical education field use

Competing interests
Financial disclosure: The authors indicate that they have no financial relationships relevant to this article to disclose. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Potential conflict of interest: The authors indicate that they have no potential conflicts of interest to disclose.

Authors' contributions
Dr. Mogi and Dr. Nishigori conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript.
Dr. Kodama and Dr. Doi collected data, carried out the initial analyses, and reviewed and revised the manuscript.
Dr. Konishi conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.   The structure of PETAP. All participants attend a lecture and then groups of five participants, with two to three facilitators, conduct a role play, which has been standardized Figure 2 The schedule of the PETAP