{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T01:24:50Z","timestamp":1778549090212,"version":"3.51.4"},"reference-count":37,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,7,26]],"date-time":"2022-07-26T00:00:00Z","timestamp":1658793600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>We conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom\u00a9). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>There was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; <jats:italic>p<\/jats:italic> &amp;lt; 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), <jats:italic>p<\/jats:italic> &amp;lt; 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (<jats:italic>p<\/jats:italic> &amp;lt; 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (<jats:italic>p<\/jats:italic> &amp;lt; 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (<jats:italic>p<\/jats:italic> &amp;lt; 0.001) and real patient care in post intervention (<jats:italic>p<\/jats:italic> &amp;lt; 0.05).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Telesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fped.2022.904846","type":"journal-article","created":{"date-parts":[[2022,7,27]],"date-time":"2022-07-27T11:30:39Z","timestamp":1658921439000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":17,"title":["Low-Cost \u201cTelesimulation\u201d Training Improves Real Patient Pediatric Shock Outcomes in India"],"prefix":"10.3389","volume":"10","author":[{"given":"Ebor Jacob G.","family":"James","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Siva","family":"Vyasam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shakthi","family":"Venkatachalam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Sanseau","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kyle","family":"Cassidy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Geethanjali","family":"Ramachandra","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Grace","family":"Rebekah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Debasis D.","family":"Adhikari","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ellen","family":"Deutsch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Akira","family":"Nishisaki","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vinay M.","family":"Nadkarni","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2022,7,26]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"686","DOI":"10.1097\/PCC.0b013e3182917fad","article-title":"Trends in the epidemiology of pediatric severe sepsis.","volume":"14","author":"Hartman","year":"2013","journal-title":"Pediatr Crit Care Med."},{"key":"B2","doi-asserted-by":"publisher","first-page":"828","DOI":"10.1097\/PCC.0000000000000254","article-title":"Pediatric severe sepsis: current trends and outcomes from the pediatric health information systems database.","volume":"15","author":"Ruth","year":"2014","journal-title":"Pediatr Crit Care Med."},{"key":"B3","year":"2007","journal-title":"Emergency Care for Children: Growing Pains."},{"key":"B4","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2018-2459","article-title":"Pediatric readiness in the emergency department.","volume":"142","author":"Remick","year":"2018","journal-title":"Pediatrics."},{"key":"B5","first-page":"226","article-title":"An international perspective on the treatment of pediatric shock: the Brazilian experience.","volume":"6","author":"Viana","year":"1998","journal-title":"New Horiz."},{"key":"B6","doi-asserted-by":"crossref","first-page":"e52","DOI":"10.1097\/PCC.0000000000002198","article-title":"Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children.","volume":"21","author":"Weiss","year":"2020","journal-title":"Pediatr Crit Care Med."},{"key":"B7","doi-asserted-by":"publisher","first-page":"403.e","DOI":"10.1016\/j.jemermed.2015.08.004","article-title":"Disparities in adherence to pediatric sepsis guidelines across a spectrum of emergency departments: a multicenter, cross-sectional observational in situ simulation study.","volume":"50","author":"Kessler","year":"2016","journal-title":"J Emerg Med."},{"key":"B8","doi-asserted-by":"crossref","first-page":"e514","DOI":"10.1542\/neo.15-12-e514","article-title":"Educational perspectives: telesimulation in neonatal resuscitation.","volume":"15","author":"Manhas","year":"2014","journal-title":"NeoReviews."},{"key":"B9","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1097\/PEC.0000000000000752","article-title":"The effectiveness of remote facilitation in simulation-based pediatric resuscitation training for medical students.","volume":"33","author":"Ohta","year":"2017","journal-title":"Pediatr Emerg Care."},{"key":"B10","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1002\/aet2.10015","article-title":"Telesimulation: an innovative tool for health professions education.","volume":"1","author":"McCoy","year":"2017","journal-title":"AEM Educ Train."},{"key":"B11","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1590\/S0120-41572013000100013","article-title":"Fundamentals of laparoscopic surgery in Colombia using telesimulation: an effective educational tool for distance learning.","volume":"33","author":"Henao","year":"2013","journal-title":"Biomedica."},{"key":"B12","doi-asserted-by":"publisher","first-page":"995","DOI":"10.1111\/aas.12695","article-title":"Teaching ultrasound-guided regional anesthesia remotely: a feasibility study.","volume":"60","author":"Burckett-St Laurent","year":"2016","journal-title":"Acta Anaesthesiol Scand."},{"key":"B13","first-page":"379","article-title":"Transatlantic medical education: preliminary data on distance-based high-fidelity human patient simulation training.","volume":"94","author":"von Lubitz","year":"2003","journal-title":"Stud Health Technol Inform."},{"key":"B14","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1097\/AAP.0000000000000165","article-title":"A valid and reliable assessment tool for remote simulation-based ultrasound-guided regional anesthesia.","volume":"39","author":"Laurent","year":"2014","journal-title":"Reg Anesth Pain Med."},{"key":"B15","doi-asserted-by":"publisher","first-page":"229","DOI":"10.1016\/j.mayocpiqo.2018.06.008","article-title":"Feasibility of an international remote simulation training program in critical care delivery: a pilot study.","volume":"2","author":"Shao","year":"2018","journal-title":"Mayo Clin Proc Innov Qual Outcomes."},{"key":"B16","year":"2020","journal-title":"Healthcare Simulation Dictionary \u2013 AHRQ Publication No. 20-0019."},{"key":"B17","author":"Auerbach","year":"2022","journal-title":"ACEP SimBox."},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1002\/aet2.10590","article-title":"TeleSimBox: a perceived effective alternative for experiential learning for medical student education with social distancing requirements.","volume":"5","author":"Sanseau","year":"2021","journal-title":"AEM Educ Train."},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.16317","article-title":"How to use TeleSimBox \u201coff the shelf\u201d to connect remote content experts with in-person simulation participants.","volume":"13","author":"Sanseau","year":"2021","journal-title":"Cureus."},{"key":"B20","doi-asserted-by":"publisher","first-page":"818.e","DOI":"10.1016\/j.jen.2021.01.013","article-title":"Development and implementation of a pediatric telesimulation intervention for nurses in community emergency departments.","volume":"47","author":"Montgomery","year":"2021","journal-title":"J Emerg Nurs."},{"key":"B21","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1016\/j.annemergmed.2021.03.040","article-title":"ACEP SimBox: a pediatric simulation-based training innovation.","volume":"78","author":"Vora","year":"2021","journal-title":"Ann Emerg Med."},{"key":"B22","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/S1473-3099(14)71003-5","article-title":"Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002\u201313: a multicenter retrospective cohort study.","volume":"15","author":"Schlapbach","year":"2015","journal-title":"Lancet Infect Dis."},{"key":"B23","year":"","journal-title":"In: Merriam-Webster."},{"key":"B24","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1097\/01.PCC.0000149131.72248.E6","article-title":"International consensus conference on pediatric sepsis. international pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.","volume":"6","author":"Goldstein","year":"2005","journal-title":"Pediatr Crit Care Med."},{"key":"B25","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1097\/SIH.0000000000000267","article-title":"The development and validation of a concise instrument for formative assessment of team leader performance during simulated pediatric resuscitations.","volume":"13","author":"Nadkarni","year":"2018","journal-title":"Simul Healthc."},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1186\/s41077-021-00173-1","article-title":"Embracing informed learner self-assessment during debriefing: the art of plus-delta.","volume":"6","author":"Cheng","year":"2021","journal-title":"Adv Simul."},{"key":"B27","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s41077-020-00141-1","article-title":"A practical guide to virtual debriefings: communities of inquiry perspective.","volume":"5","author":"Cheng","year":"2020","journal-title":"Adv Simul."},{"key":"B28","doi-asserted-by":"publisher","first-page":"1099","DOI":"10.1016\/j.resuscitation.2014.05.005","article-title":"Increasing pediatric resident simulated resuscitation performance: a standardized simulation-based curriculum.","volume":"85","author":"Stone","year":"2014","journal-title":"Resuscitation."},{"key":"B29","doi-asserted-by":"publisher","first-page":"e1313","DOI":"10.1542\/peds.2013-2139","article-title":"Technology-enhanced simulation and pediatric education: a meta-analysis.","volume":"133","author":"Cheng","year":"2014","journal-title":"Pediatrics."},{"key":"B30","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1136\/bmjstel-2021-000875","article-title":"Closing the gap: a call for a common blueprint for remote distance telesimulation.","volume":"7","author":"Duff","year":"2021","journal-title":"BMJ Simul Technol Enhanc Learn."},{"key":"B31","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1136\/bmjstel-2020-000671","article-title":"Remote rapid cycle deliberate practice simulation training during the COVID-19 pandemic.","volume":"7","author":"Balmaks","year":"2020","journal-title":"BMJ Simul Technol Enhanc Learn."},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.2196\/14587","article-title":"Evaluation of a mobile telesimulation unit to train rural and remote practitioners on high-acuity low-occurrence procedures: pilot randomized controlled trial.","volume":"21","author":"Jewer","year":"2019","journal-title":"J Med Internet Res."},{"key":"B33","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1097\/SIH.0b013e31822eacae","article-title":"Low-cost and ready-to-go remote-facilitated simulation-based learning.","volume":"7","author":"Ikeyama","year":"2012","journal-title":"Simul Healthc."},{"key":"B34","doi-asserted-by":"crossref","first-page":"4033","DOI":"10.1007\/s00464-013-3048-7","article-title":"Feasibility of remote administration of the fundamentals of laparoscopic surgery (FLS) skills test.","volume":"27","author":"Okrainec","year":"2013","journal-title":"Surg Endosc."},{"key":"B35","author":"Kirkpatrick","year":"2006","journal-title":"Evaluating Training Programs: The Four Levels."},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2015-4153","article-title":"High reliability pediatric septic shock quality improvement initiative and decreasing mortality.","volume":"138","author":"Lane","year":"2016","journal-title":"Pediatrics."},{"key":"B37","doi-asserted-by":"publisher","first-page":"810","DOI":"10.1097\/PEC.0b013e31818e9f3a","article-title":"Time-and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American college of critical care medicine\/pediatric advanced life support guidelines in a pediatric intensive care unit in a developing world.","volume":"24","author":"Oliveira","year":"2008","journal-title":"Pediatr Emerg Care."}],"container-title":["Frontiers in Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2022.904846\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,7,27]],"date-time":"2022-07-27T11:30:46Z","timestamp":1658921446000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2022.904846\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,7,26]]},"references-count":37,"alternative-id":["10.3389\/fped.2022.904846"],"URL":"https:\/\/doi.org\/10.3389\/fped.2022.904846","relation":{},"ISSN":["2296-2360"],"issn-type":[{"value":"2296-2360","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,7,26]]},"article-number":"904846"}}