Brue Curricular Proposal Final Document

A Proposed Curriculum to
Improve the Practice of

pediatricians in the Diagnosis
and Management of Infant
Events
Adam Cohen, MD
Pediatric Hospital Medicine Fellow
Baylor College of Medicine/Texas Children’s Hospital
adcohen.md@gmail.com
A Proposed Curriculum to Improve the Practice of Pediatricians in the Diagnosis and Management of Infant Events
Table of Contents
PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT..................................................................................................... 2
HEALTH CARE PROBLEM ADDRESSED BY THE CURRICULUM ...............................................................................................................................2
POPULATIONS AFFECTED BY THE PROBLEM....................................................................................................................................................2
EFFECTS OF THE PROBLEM..........................................................................................................................................................................3
DESCRIPTION OF DIFFERENCE BETWEEN CURRENT AND IDEAL APPROACHES.........................................................................................................4
TARGETED NEEDS ASSESSMENT..................................................................................................................................................... 6
DESCRIPTION OF TARGETED LEARNERS..........................................................................................................................................................6
DESCRIPTION OF THE TARGETED LEARNING ENVIRONMENT...............................................................................................................................6
DESCRIPTION OF THE STAKEHOLDERS............................................................................................................................................................7
INFORMATION THAT NEEDS CLARIFICATION...................................................................................................................................................8
PROPOSAL FOR INITIAL NEEDS ASSESSMENT...................................................................................................................................................8
GOALS AND OBJECTIVES................................................................................................................................................................ 9
PROPOSED EDUCATIONAL GOALS.................................................................................................................................................................9
PROPOSED EDUCATIONAL OBJECTIVES.......................................................................................................................................................... 9
EXAMPLE EDUCATIONAL STRATEGIES.......................................................................................................................................... 11
TABLE 3: EXAMPLE EDUCATIONAL STRATEGIES BASED ON SELECTED OBJECTIVE.................................................................................................11
EXAMPLE OF EDUCATIONAL METHODS THAT ARE LEARNER-CENTERED OR PROMOTE SELF-DIRECTED LEARNING.......................................................12
EXAMPLE OF EDUCATIONAL STRATEGIES THAT PROMOTE PRACTICE-BASED LEARNING AND IMPROVEMENT OR SYSTEMS-BASED PRACTICE....................12
EXAMPLE OF EDUCATIONAL STRATEGIES THAT PROMOTE PROFESSIONALISM......................................................................................................12
RESOURCES AND FEASIBILITY OF ABOVE STRATEGIES......................................................................................................................................12
IMPLEMENTATION....................................................................................................................................................................... 13
RESOURCES NEEDED FOR IDEAL CURRICULUM..............................................................................................................................................13
INSTITUTIONAL SUPPORT.......................................................................................................................................................................... 14
PROPOSED ADMINISTRATIVE STRUCTURE.....................................................................................................................................................14
BARRIERS TO IMPLEMENTATION AND STRATEGIES TO OVERCOME THEM...........................................................................................................14
PROPOSED IMPLEMENTATION PLAN........................................................................................................................................................... 15
EVALUATION AND FEEDBACK....................................................................................................................................................... 16
USERS OF THE EVALUATION...................................................................................................................................................................... 16
USER NEEDS.......................................................................................................................................................................................... 16
POTENTIAL RESOURCES AVAILABLE FOR EVALUATION.....................................................................................................................................16
PROPOSED EVALUATION QUESTIONS.......................................................................................................................................................... 16
RELATING EVALUATION QUESTIONS TO CURRICULAR OBJECTIVES.....................................................................................................................17
PROPOSED EVALUATION DESIGN................................................................................................................................................................17
PROPOSED EVALUATION METHODS AND RESOURCES NEEDED.........................................................................................................................17
ETHICAL CONCERNS.................................................................................................................................................................................17
DATA COLLECTION PROCESS..................................................................................................................................................................... 18
DATA ANALYSIS PLAN.............................................................................................................................................................................. 18
PROPOSED FORMAT FOR EVALUATION REPORTS...........................................................................................................................................18
REFERENCES................................................................................................................................................................................ 19
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Problem Identification and General Needs Assessment
Health Care Problem Addressed by the Curriculum

In 2016, The American Academy of Pediatrics released a paradigm-shifting clinical practice guideline on the diagnosis,
evaluation, and management of the Apparent Life-Threatening Event (ALTE). The new guideline replaced the term ALTE with a
new term, Brief Resolved Unexplained Event (BRUE), which has a more specific clinical definition 1. The major difference in the
two terms is that BRUE, as opposed to ALTE, only applies to patients when there is no explanation for a qualifying event after
a thorough history and physical exam, and that the event is resolved by the time the patient presents to a physician. This
definition is much more precise, as evidenced by recent studies showing that only 23-58% of patients diagnosed with ALTE
retrospectively met the definition of BRUE2,3. Despite this large change, there have been very few educational efforts put in
place for pediatricians to learn about these changes and how to apply them. In addition, the bulk of the clinical practice
guideline is focused specifically on identifying which patients diagnosed with BRUE are low risk, and not providing guidance for
the significant population of children who are diagnosed as having a non-BRUE event. In a brief poll of pediatric hospitalists at
one large pediatric center, children with either a clear explanation for the event or continued symptoms have been
consistently misdiagnosed as BRUE, many of which received evaluation or admission to the hospital inconsistent with current
guidelines or the clinical appearance of the child. Furthermore, there are clear guidelines for low-risk infants, which
recommends against most routine testing and admission to the hospital for observation, which is a large change from prior
common practice.
To summarize: the AAP’s Clinical Practice Guidelines regarding the diagnosis and management of BRUE are a large change
from prior management, and while they define this new diagnosis and provide guidance on the management of the low risk
population, physicians are left with little guidance on two major populations of children, those who are high risk and those
with non-BRUE events. In addition, there are currently very few efforts aimed towards the dissemination and correct use of
these guidelines. As research has shown, the release of clinical practice guidelines alone does not translate well into patient
care without sustained efforts towards education and reinforcement5,6. Therefore, many clinicians are likely slow to
appropriately implement the guidelines into their clinical practice. An educational tool may be a useful first step in the effort
to implement this guideline in clinical practice and provide clinical guidance for the significant population of children who
present with a non-BRUE event.
Populations Affected by the Problem
Patients
Infants who present to health care for BRUE and non-BRUE events, as well as their parents, caregivers, and families who
access health care with them. Many caregivers give up time at work in order to present to health care with their child, which
could have effects on overall workplace productivity and caregiver mental health.
Health Care Professionals

Physicians who act as the first line providers for infants, including primary care pediatricians, emergency department
physicians, and pediatric hospitalists, bare the primary responsibility on deciding the plan of care for patients who present
with these events. Their familiarity and ability to apply the guidelines is paramount in the proper care of these children. In
addition, many emergency department physicians are not trained in pediatrics, and may not have awareness or comfort with
the new guidelines. Furthermore, nursing and ancillary hospital and clinic staff can also be affected, as they are the front-line
medical personnel who interact with the patients and families.
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Medical Educators
The development of a curriculum to encompass these new guidelines could be of interest to fellow educators who are
involved in faculty development and pediatrics training as a means of education for themselves and their students.
Society
Health-care systems, networks, hospitals, and clinics are ultimately the responsible organization in the management of these
children. Stricter adherence to these guidelines can benefit these networks, including potentially in cost savings, and allow for
safer care of infants with events. With the onset of changing reimbursements and bundled payments, networks and payors
are beginning to look more closely at ways to decrease cost, and the heart of this guideline is to reduce unnecessary care in
patients who present with events.
Effects of the Problem
Cost/Value
Unnecessary care and testing are major causes of the ballooned national health care spending, in addition to the personal cost
to a family for an infant who receives an unnecessary hospitalization. Over a six-month period at Texas Children’s hospital,
there have been over 100 admissions with the diagnosis of BRUE or ALTE. With an average cost of hospitalization of $4500 per
patient4, even if only 25% of these admissions are unnecessary, there could be over $100,000 in wasted health-care
expenditure in a 6-month period.
Emotional Harm
Emotional effects also need to be taken into account, as hospital admission and testing can invoke many emotional responses
from families and caregivers, including fear, stress, anxiety and depression. Furthermore, moral distress can affect providers
and medical personnel who see patients being managed according to standards other than the most up-to-date evidence-
based guidelines, which may precipitate anxiety and burn-out.
Medical Complications from Unnecessary Testing

Without adherence to the guideline, infants who present with events could be managed in an inconsistent and potentially
unsafe way. Many patients who would previous require admission to the hospital or multiple blood tests under older methods
of practice now only require anticipatory guidance and regular follow up with a Pediatrician. Risks of hospitalizations and
unnecessary work up are well documented, but could include exposure to new pathogens, injury or unnecessary procedures.
Medico-legal
Part of the modern role of health care professionals includes using the most up to date evidence to steer the treatment of
their patients. Not only is it a moral imperative to take the best care of your patient possible, physicians and other health care
providers could be held legally liable for any complications of the misinterpretation of guidelines or incorrect use of evidence.
Medical Education
Continuing to not follow evidence-based medicine perpetuates incorrect concepts to medical learners. In the long term, this
may contribute to future physicians who provide decreased quality of care and who display hesitancy in the following of other
evidence-based guidelines.
Table 1: Current and Ideal Approaches to Address the Problem

Patients Health Care Medical Educators Policymakers
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Professionals
Present to health care Some providers keep Individual bedside The AAP has created
professionals for care current with guidelines, teaching with pediatric and disseminated the
after their infant has a some apply guidelines learners based on clinical practice
concerning event. without fully whatever the current guideline through a
understanding how, and practice of the senior single issue of a journal.
others continue to healthcare professional One webinar advertised
practice based on older is. The ABP does not to clinicians at time of
Current Approach
evidence. include BRUE or ALTE in guideline publication
the 2017 General was created and
Pediatrics Content released, which is now
Outline for the General buried on the AAP
Pediatrics Board Exam. website. The AAP also
created patient
information sheet.
Learn about care of Practice and teach care Use individual bedside Continued re-education
events from physicians of infant events based teaching with pediatric efforts at conferences,
and policymakers, such on the most recent any learner who may be via repeated online
as the AAP official clinical practice responsible for a webinars, and outreach
patient information guidelines and pediatric patient as a to organizations
sheets. Present to care recognize that there are supplement to a responsible for the care
during an event and gray areas which thorough curriculum of infants. Also,
advocate for the best require discussion and which emphasizes the outreach to non-
care for their child. clinical judgement on a use of the evidence- physicians, including
Ideal
per patient basis. based clinical practice nurses, techs, and
Approach
Hospitals can also guidelines. The patients. Support for QI
create reminders as curriculum should be initiatives and the use
well as audit and backed by the creation of standardized
feedback systems in QI of content educational materials
related interventions to specifications
improve guideline determined by the ABP,
adherence. ACGME and other
governing educational
bodies.
Description of Difference between Current and Ideal Approaches

The major differences between the current and ideal approaches are two-fold: 1) the lack of a thorough curriculum to teach
medical learners and current practitioners about the new clinical practice guideline, including a lack recognition from
educational organizations, and 2) the lack of concerted efforts and outreach to ensure the education is disseminated and the
guidelines are followed. While there are multiple ways to address these large differences and multiple levels of people to
guide and teach, beginning with a curriculum to teach the primary providers of care for infants with events may have a
waterfall effect. The primary providers can pass their education to medical learners as well as the patients.
In addition, larger outreach efforts by national organizations targeting both providers and patients, improvement in the CME
system to encourage longitudinal learning, and efforts to enhance guideline visibility and uptake by hospital systems can also
contribute to the adequate dissemination and application of these guidelines to clinical care. Many of these strategies would
require, or at least be boosted by, significant administrative support, which could be garnered by the demonstration of cost
effectiveness when following the guidelines.
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Finally, continued research to allow for the refinement of these guidelines are ultimately necessary for optimal care of the
infant with a concerning event.
Table 2: Knowledge Deficiencies and Correction Strategies

Knowledge Deficiency Methods to Correct Deficiency
Current local and national efforts and outreach related Informal consultation with local and national experts
to the dissemination and acceptance of the guidelines
Current hospital-based educational efforts, at my Survey of educational leaders at multiple healthcare
current place of work and at other hospital systems systems to understand current efforts and
implementation barriers
Parental/societal understanding of infant events Survey of patients and child advocacy groups
Physician understanding of the guidelines and their Survey of pediatric providers (hospitalist, emergency
effect on infant event management and primary care) regarding implementation and use of
the guidelines
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Targeted Needs Assessment
Description of Targeted Learners

Training front-line pediatric providers at my targeted institution, including primary care, emergency care and hospital
pediatricians, will have the largest impact on the correct diagnosis and management of BRUE and non-BRUE events as they are
the pediatricians who determine the care and disposition of these infants. In addition, these three groups of pediatricians are
a large portion of the teaching faculty at most children’s hospitals; if they begin to practice with the most up-to-date
recommendations, the learning should disseminate to the many pediatric trainees at these institutions as well.
The large majority of these front-line providers have completed a 3-year pediatric residency and have multiple years of
experience in various settings of pediatric practice. In addition, the many of them were trained prior to the release of the
BRUE clinical practice guidelines and have much more familiarity with the diagnosis and management of ALTE, the older
terminology and practice recommendations. The term ALTE was in use since 1986 as a descriptive term for infants who
present with concerning events, however, it was frequently difficult to apply to clinical care. Therefore, many physicians
created their own methods of practice concerning these events, which frequently involved hospital admission or testing 7. In
addition, there are adult-trained emergency physicians who undergo some pediatric emergency training who have even less
familiarity and formal training in the diagnosis and management of these events.
In regards to their attitudes, each of these groups of physicians tend to have different priorities in terms of patient care. An
emergency pediatrician needs to quickly determine whether the child is in danger and be able to transition them to the next
level of care (home vs hospital vs ICU). Many of them are uncomfortable when a quick diagnosis cannot be made or when
they are restricted in their use of diagnostic work-up without a strong evidence base that shows it is a safe way to practice. A
primary care pediatrician follows these patients throughout their lives, managing their long-term health and building strong
therapeutic alliances with their families. They need to make sure the long-term risks to a patient with a health problem is
minimized. A hospital pediatrician’s job is to diagnose an underlying condition and improve their health enough that they are
ready to be transitioned to the outpatient setting. Because of these different priorities of care, they all have different
perspectives on what care needs to happen. However, if evidence shows a best course of action, they are all driven towards
that course.
Many of these physicians have busy clinical and administrative schedules, making it a challenge to incorporate continuing
education and faculty development programs. As these physicians are adult learners, the educational programs which target
them need to be accessible at convenient times, relevant to their practice and job satisfaction, and designed to accommodate
multiple different styles of learning8. With the vast majority of physicians being required to use electronic health records and
other forms of electronic learning in maintenance of certification, familiarity of these populations to technology-based
learning methods is high.
Description of the Targeted Learning Environment

Currently, at the targeted institution, there is no formal curriculum in place which covers the BRUE guidelines for the faculty
physicians. There are online resources, such as a reformatted version of the guidelines, available on the hospital’s intranet
page. There have also been scattered attempts by each department individually through staff meetings or lectures to
disseminate the new guidelines. In addition to the lack of faculty education, there is no formal resident education in place
either.
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One of the largest challenges to developing this curriculum is in the diversity and large number of learners in which it targets.
The group of faculty at the targeted institution all have different levels of experience, opinions, and management frameworks
regarding the diagnosis of infant events. Even though they all have a functional working knowledge of educational technology
as CME and MOC move towards more technologically advance methods, the depth of the knowledge and preference for
different educational styles may largely vary among the faculty. Another barrier would be the time available to the curriculum
development team, which is currently a one-person team.
In terms of supporting factors, the targeted institution has a culture for improving education and provides access to a variety
of available educational resources. Furthermore, as there is not current educational curriculum in place, and there is a
growing body of evidence on the benefits of appropriate implementation of these guidelines, 2,3 there is a strong theoretical
basis for faculty and leadership buy-in.
The largest barrier to implementation of a new curriculum is time, given the busy faculty schedules and multitude of other
required administrative and educational work which they are required to do. Furthermore, with a wide-spread medical
campus and hundreds of faculty members who would potentially be accessing this curriculum, creative solutions would need
to be used in order to implement the curriculum to the target learners. This may need to include asynchronous learning
techniques as well as taking advantage of already scheduled education time for faculty, including departmental meetings and
CME opportunities. Even with these solutions, disseminating educational material and creating incentives to access the
material provides its own set of challenges. Finally, a key to adult learning is maintenance of the knowledge, which may
require longer term efforts that are difficult to sustain.
Supportive factors and resources include multiple electronic educational platforms which are already in use at the targeted
institution to provide continuing education and faculty development to the learners. Furthermore, in all of the departments
there are time-protected meetings with a focus on continuing education. An informal survey of educational leaders in these
departments shows that there is a desire for education resources on the topic, which suggests there would be leadership buy-
in to a new curriculum. Finally, leadership support is a major boon towards implementation of the curriculum.
Description of the Stakeholders

Faculty Leadership/Hospital Administration
Section and Department chairs have a vested interest in their faculty practicing with the most up-to-date evidence, as well as
ensuring they are clinically productive. Their needs include ensuring faculty education is not only effective, but also efficient
without distracting from their clinical load.
Residency and Student Educational Leadership

As these faculty members make up a large part of the teaching faculty at the institution, educational leadership would be
invested in any efforts to improve faculty adherence to evidence-based guidelines. Any change in faculty practice may change
the lens through which residents and students are evaluated. They would likely need access to the materials in order to
change and disseminate them for resident and student involvement.
Front-line faculty
As the targeted learners, they are a major stakeholder in the implementation of the curriculum. Their needs include a
curriculum which is accessible, efficient and relevant to the patients and environments in which they practice.
Nursing Faculty and Leadership

They act as a major source of education at academic centers, and having nurses with an understanding of the diagnosis can
help drive further educational efforts and guideline adherence.
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AAP and Other Accrediting Bodies

Their overall needs include having their respective members follow their guidelines and receive appropriate compensation for
their resources. They may be able to provide CME credit for activities which are congruent with these needs.
Patients/Families
Their needs include receiving safe, effective and evidence-based care, as well as understanding their conditions and what the
need to do.
Information That Needs Clarification

Practicing Physicians’ Attitudes and Knowledge about the BRUE Clinical Practice Guidelines
For example, their opinions on the usefulness of implementation and how it affects their patients. Many of them may not
even know the guidelines exist. This knowledge would help design a curriculum which motivates the physicians to learn the
material.
The Learning Preferences and Styles of the Targeted Learners

More robust information would allow for the creation of a multi-part curriculum that could match the learning styles of a large
majority of the faculty, increasing the effectiveness of the curriculum.
Faculty Familiarity with Different Asynchronous Learning Techniques

As this curriculum needs to reach a large number of physicians with widespread areas of practice, at least part may need to be
asynchronous. Using technology and programs with which faculty are already familiar will allow for easier dissemination and
use. However, if there is hesitancy towards these techniques, or preference for face-to-face or in-classroom teaching, an
asynchronous style may be suboptimal.
Proposal for Initial Needs Assessment

The most efficient and feasible method to obtain this information would be via survey. This would likely take the form of a
questionnaire with a mixture of Likert scale and open-ended questions inquiring about the attitudes, preferences and
experiences of the targeted learner group. Dissemination of such a survey would be achievable through section and
department list-servs. The main challenge would be ensuring an adequate response rate. Resources needed would include an
electronic survey platform such as SurveyMonkey or RedCap and an experienced survey designer to assist in question
development and semantics, ensuring all questions are balanced and unbiased. Other resources which could helpful would
include a champion in each department to improve survey response rate and rewards for survey completion. Statistical
support would be helpful as well, even if this likely only needs descriptive statistics to assist in identifying needs and
preferences. If response rate was low, I could consider personally delivering paper questionnaires or holding a few focus
group sessions.
For initial piloting of the survey, I would choose educational leaders from each of the departments, including the Vice Chair of
Education in charge of faculty development. Not only will these physicians have intimate knowledge of their own departments
and the current educational climate, but they will also have content expertise which can help refine the questionnaire to yield
useful results. The major weakness is some of these faculty may have lower clinical loads than other physicians in their
departments, so I would have to take that into account prior to disseminating the survey to all faculty.
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Goals and Objectives

Proposed Educational Goals
1. After completion of this curriculum, Emergency, Primary Care, and Hospital Pediatricians will have the knowledge,
skills and attitudes necessary to appropriately diagnose and manage the infant who presents with a BRUE or non-
BRUE event in multiple settings of pediatric care.
2. These pediatric providers will also gain a working knowledge of the current BRUE guidelines, including their strengths
and weakness, and recognize the current gaps in the literature.
Relation of Goals to Defined Competencies

As medical education has moved towards competency-based standards, the Accreditation Council for Graduate Medical
Education, the governing body for residency education, has transitioned the residency evaluation process to a competency-
based format called Milestones. These Milestones essentially act as guidelines for areas which residents should be competent
in at the completion of their training and the start of their career as a Pediatrician, and therefore are applicable as standards
for all currently practicing pediatricians. The most recent version released in July of 2017 list the following Milestones which
are relevant to this curriculum9:
 PC4: Make informed diagnostic and therapeutic decisions that result in optimal clinical judgement
 PC5: Develop and carry out management plans
 MK1: Critically evaluate and apply current medical information and scientific evidence for patient care
 PBLI2: Identify and perform appropriate learning activities to guide personal and professional development
 PROF6: Recognize that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate
resources in dealing with uncertainty
Proposed Educational Objectives

At the end of the curriculum, pediatricians will:
1. Define all 5 diagnostic criteria and all 7 low risk criteria for BRUE with 100% accuracy when prompted.
2. List all 6 of the 6 common comparisons between ALTE and BRUE.
3. Apply the diagnostic criteria and low risk algorithm to accurately identify an event as BRUE, low risk BRUE, or other
infant event in 4 out of 5 provided example cases.
4. Recognize that the management of infant events not classified as low risk BRUE is currently not evidence-based and
should be up to the clinical judgement of the infants’ care team.
5. Identify current local guidelines regarding the diagnosis and management of patients presenting with BRUE.
6. Identify 2 new literature sources which can assist them in the management of patients with BRUE.
By the end of 2019, 80% of all Emergency Center, Hospital Medicine, and Primary Care Pediatricians will have appropriately
followed the BRUE algorithm in the diagnosis and management of an infant with a concerning event at least once, as obtained
via survey.
Relation of Objectives to Goals

The educational goals above broadly refer to education surrounding the appropriate diagnosis and management of infant
events, as well as global familiarity with the current recommendations and body of literature. Each objective listed above
builds into this goal by describing specific knowledge, skills and attitudes which a pediatrician, program, or health-care system
would need in order to meet that goal. Specifically, by learning about and demonstrating the use of the diagnostic criteria and
algorithms, identifying the changes in current practices compared to older ones, and expanding their knowledge set through
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literature review, pediatricians will improve their understanding of the most up-to-date recommendations, which can
translate into an improved practice.
Relation of Objectives to Competencies

Defining and applying the diagnostic criteria and low risk criteria will allow pediatricians to make informed diagnostic and
therapeutic management decisions and develop and carry out management plans.
Comparing ALTE (old practices) and BRUE (current practices) and identifying new literature sources will help pediatricians
critically evaluate and apply current information and evidence for patient care.
Appreciating and reflecting that there is a literature gap surrounding non-low risk BRUEs and non-BRUE events will allow
pediatricians to recognize the ambiguity in clinical medicine and learn how to apply resources in dealing with the uncertainty.
Recognizing the appropriate locations of critical and new resources, including current guidelines and algorithms, will help
pediatricians guide their professional development through learning.
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Example Educational Strategies

Table 3: Example Educational Strategies Based on Selected Objective
Cognitive Affective Psychomotor
(Knowledge) (Attitudinal) (Skill or Performance)
Specific At the end of the curriculum, At the end of the curriculum, At the end of the curriculum,
measurable pediatricians will define all 5 pediatricians will recognize that pediatricians will apply the
objectives diagnostic criteria and all 7 low risk the management of infant diagnostic criteria and low risk
criteria for BRUE with 100% accuracy events not classified as low risk algorithm to accurately identify
when prompted. BRUE is currently not evidence- an event as BRUE, low risk BRUE,
based and should be up to the or other infant event in 4 out of 5
clinical judgement of the infants’ test cases.
care team.
Educational Lecture or online interactive module Large group discussion Simulation – online cases or small
method to with group polling, ability to select Role modeling group case discussions
achieve content pieces individually. Clinical practice and reflection
Educational Regular reading and materials posted Delayed reflection assignment Chart review of cases and
method to online. months after curriculum customized feedback
prevent concludes Follow up case practice months
decay after course ends
Resources An interactive lecture will require a A large group discussion also The online cases would require a
required dedicated facilitator, and given the requires dedicated facilitators software for the creation of the
number of potential learners, this and space and may also have to cases and domain hosting for
may need to be done multiple times be done at multiple times and in learner access for both initial use
and in multiple spaces. This may multiple spaces. The reflective and follow up cases. It would also
require multiple facilitators, multiple assignment requires someone to require the correct personnel and
rooms with technology available to collect and review the expertise to create. If it takes
allow for a presentation with assignments. Both the place in a small group instead, it
interactive polling software. These facilitators and reviewers will would require trained facilitators
facilitators will need to be trained in need content knowledge and as well. Chart review with
the content and in the methods of knowledge in the methods of feedback and follow up requires a
conducting a large group learning facilitating discussion and dedicated, knowledgeable person
session. This could be mitigated by reflective writing. Role modeling or group of people with access to
changing the lecture into an would require dedicated faculty chart review who are willing to
interactive online module, which who are already trained in provide useful, reinforcing and
would require the necessary software appropriate care to serve as the constructive feedback.
and domain hosting. Online posting of role models.
resources will require a dedicated
domain, someone in charge of
updating the resources, and a list of
contact information from former
learners to share these updates. It
would also require the correct
personnel and expertise to create,
specifically in terms of content,
technology and medical education
expertise.
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Example of Educational Methods that are Learner-Centered or Promote Self-Directed Learning.

One educational method that is learner-centered would be a self-paced, self-directed online module for the knowledge
acquisition part of the curriculum. The module would be available to access through multiple devices, and learners would be
able to access each objective-focused piece as few times or as often as they need for review of the key concepts. It would
include question-and-answer-based assignments and simulated cases which would allow for self-testing and reflection on
knowledge gained. Content would be available in multiple formats, including outline, slides or audio/video lectures.
Example of Educational Strategies that Promote Practice-Based Learning and Improvement or

Systems-Based Practice.
One strategy that could promote Practice-Based Learning and Improvement is an independent learning assignment that
includes reading and critiquing a recent article related to the curricular topic and discussing the article with the large group. It
would focus on how the article informs or changes their practice. This could also include a discussion on the resources needed
and feasibility to implement this practice change. They would be asked to critique the methods involved to know the study
quality is high enough to affect practice. This would promote the learner’s ability to improve their practice through the
appraisal and assimilation of scientific evidence.
Example of Educational Strategies that Promote Professionalism.

In order to promote professionalism, the discussion and reflection pieces of the curriculum could also include a question or
prompt related to incorporating the values of professionalism into each individual’s practice in the management of infant
events. This could include topics such as discussing effective communication, a commitment to excellence in patient care, and
shared decision making, which is particularly relevant when discussing a syndrome which may not always have an obvious
diagnosis. Learners could also be prompted to reflect on how different decisions may affect each provider involved in the
child’s care.
Resources and Feasibility of Above Strategies

With the consideration of the principles of learner-centeredness, practice-based learning and improvement, and
professionalism, my initially proposed strategies may need to expand significantly. An interactive module which is self-paced
and allows for repeated exposure to the specific pieces of the content may be much harder to create effectively than a video
lecture posted on a website. Expanding the discussion and reflection assignments to include practice-based learning and
multiple concepts of professionalism may end up being too complex for a single session or assignment, thereby multiplying
the resources needed. In terms of feasibility, changing from lectures to online modules increases the up-front work-load, but
allows the curriculum to be more sustainable in the long run, which may make it more feasible. However, some of the
discussion/reflection-based assignments may have to be pared down due to limited availability of faculty, time and space.
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Implementation
Resources Needed for Ideal Curriculum
Personnel
 Curriculum director: with subject matter and curricular design/implementation expertise
 Faculty/Instructors: trained in large group and small group discussion
o number would depend on number of students, but can assume 50 students/year, meaning 1 large group and
5-10 small group facilitators.
o May also need to assist in grading reflective essay and/or compiling grade for each student
 Support Staff:
o Curriculum administrator to organize time and place for group discussions and distribute curriculum
materials to student
o IT support to set up online modules
Time
 Each faculty/instructor would need 1 hour for each session they lead, plus additional time for preparation, feedback,
grading and reading reflective assignments
 The curriculum director (me) would need time during the curriculum to coordinate the other faculty, train them in the
necessary skills and knowledge, and ensure learners are meeting the learning objectives
o This director would also need time and support to build the curriculum, including technical support with the
learning management software.
Facilities
 Rooms would be needed for the discussion portions of the curriculum, although no AV equipment would be needed
for discussions
 The online components would require an online learning/education platform accessible from multiple different types
of technology to maximize learner access
 Patients would also be needed for the clinical practice piece, which will be part of each learners’ practice
Cost
 Online learning management system can be obtained through the medical institution, which has access and IT help
already available
 Facilities for the discussions will need to be reserved in advance, but will be done at the existing medical center at no
cost
 Some funding will be needed for personnel depending on ability to attract volunteers, but may include a portion of
salary for the curriculum director, compensation for the coordinator and IT specialist
 With a strong volunteer educational community, and a pro-bono curriculum director, there likely won’t be a need for
external funding initially.
Feasibility
Overall, a curriculum of this size and complexity is likely not feasible with the given resources and time currently available. The
curriculum would likely need to be down-sized to remove some or all of the discussion formats and may need to prove useful
prior to expansion. I think a feasible course to start would include a self-paced online program with multiple modules
including recorded video lectures, interactive cases, and questions to meet most learning objectives. This could also include
some short reflective essay prompts. If we are piloting with a small number of learners, this could be fully implemented and
organized by the course director (me) with IT support.
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Institutional Support
Currently, among the hospital pediatricians, as well as the Pediatric Residency program, the support for this curriculum is high,
although that could changes based on time requirements. I have not yet gauged the support of the general education faculty,
the primary care pediatricians or the emergency department physicians. The resistance will likely come from faculty who have
more time-intensive positions, as many would not want to sacrifice time towards a new endeavor. Resistance may also come
from those who would need to provide financial support for the curriculum, as there are a small number of resources
available.
Strategies to increase support and decrease resistance include a better definition of the problem at the local level. This could
include gathering data on how the lack of knowledge around this topic is affecting patients, including the added cost of patient
care, and presenting it to higher level education leadership. Even if collected over a short amount of time, the costs of
unnecessary patient admission due to diagnostic error can be extrapolated to make an impact for higher level administrators.
Buy-in from them would decrease the resistance among the rest of the faculty. Piloting the curriculum successfully among one
group of pediatricians may increase support among other sections if it is well received. If the amount of time to fulfill the
curricular requirements is reasonable, it is likely that support will be forthcoming. As said earlier, it may take some leg work,
including looking at the cost of infant events specific to our medical center. External support, such as political support and
resource materials may be helpful to garner increased internal support, and could include support from the American
Academy of Pediatrics, as they are the organization that created the guidelines in 2016.
Proposed Administrative Structure

The benefit of an online module-based curriculum is its organization through an online portal for student access and
submission of case-based responses, questions and assignments. This automates a fair amount of the administrative work
associated with this curriculum. Grading can also occur through this system. An administrative coordinator or the curriculum
director could be in charge of ensuring these materials and reports are organized in the system. They could also distribute
access to participating learners. Communication between the director, administrator and any instructors would primarily be
through email and the online portal, which could include the recruitment and instruction of the faculty. An in-person training
session would like be necessary to review facilitator skillsets and educational materials. Any decisions about the structure of
the course and the materials would have to be run through the curriculum director, while scheduling and organizational tasks
can be taken care of by the coordinator. Technical support may be required in the set-up of the online portal and modules,
which will be done with the curriculum director directly.
Barriers to Implementation and Strategies to Overcome Them

Faculty Hesitance/Resistance
As mentioned above, this could be addressed by a combination of looking into the specific costs of infant event care in the
hospital and presenting it to high-level stakeholders to garner support. If the plan to implement the curriculum involves a
scholarly approach, support and funding could be available from the AAP as well.
Lack of Volunteer Facilitators

This could be solved in a few different ways. If the intention is to keep the group discussions, we could offer incentive for
volunteering, including letters of support and certificates of completion and training. Certain promotion requirements are
based off of educational activity and output. Alternatively, the discussions could be removed or replaced with written
reflections.
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Unavailability or Inability to Use an Online Portal

Materials for the class, including audio-visual components, readings, case examples, questions, and discussion prompts, could
also be organized into a file folder and sorted by section as intended in the online module. This could be posted to shared
drive space at the hospital center or to an online drive such as Dropbox or Box for access.
Lack of Availability of a Coordinator

If this is the case, the curriculum director would likely have to assume the communication and coordination responsibilities.
This could be lessened by recruiting an assistant director to share the load, who would also be able to share in any scholarly
output associated with the curriculum.
Technical Support
Creating an online curriculum is difficult and requires careful planning and expertise with the chosen learning management
system. This process may be slow and unwieldy. Starting this process with IT support early in the planning phase of the
curriculum would allow for a better end result.
Proposed Implementation Plan

I would introduce this curriculum through a combination of piloting and slow incorporation of the target learners. I would
begin by piloting the online modules and cases, which would be the bulk of the curriculum. I would want multiple different
levels of faculty and trainees to pilot it in order to get a wide variety of opinions from people of different experiences and skill
levels. Key members of the pilot team would be a medical education expert, one or two experienced faculty from each
department of the targeted learner, and a few senior residents. This would cover a variety of experiences in both education
and clinical skill. Everyone who pilots the curriculum will be asked to take notes on any piece that is not clear or is not working
properly. I would also send them a survey with questions regarding the accessibility, applicability, ease of use, and
functionality of the online modules. Depending on the number of initial learners, interviews with the learners may also be
helpful to gather data. This feedback could be used to adjust the curriculum and methods.
After piloting, I would phase the curriculum in, starting with one section of pediatricians at a time. Since the curriculum would
be applicable to pediatric residents, emergency pediatricians, hospital pediatricians, and primary care pediatricians, starting
with one group would be a feasible way to begin. I would likely choose the hospital pediatricians, as I work closely with them,
and would likely have more support from that section. I would also trust them to give me honest and thoughtful feedback,
which I would obtain from both informal discussions and formal evaluation forms of the different modules. This would help
me revise the curriculum before expanding it to the larger audience of the other sections.
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Evaluation and Feedback

Users of the Evaluation
The curriculum users will be emergency, hospital, and primary care pediatricians, as well as general pediatrics residents. Users
of the evaluation would include these learners, as well as course instructors, the curriculum director, hospital administrators,
credentialing organizations, and educators in other hospitals (if the curriculum is published or distributed).
User Needs
The learners’ needs are to learn the material accurately, efficiently, be able to apply it to their practice to help patients. They
also need relevant feedback on specific areas of their practice to improve their performance. Testing of the knowledge of the
participants will be used to give them feedback on areas of strengths and weaknesses. They will also be assessed during the
discussion portion of the curriculum and given feedback on their grasp of the material. The evaluation of the curriculum will
also include satisfaction-based questions that will help the instructors and curriculum director improve and optimize the
curriculum for subsequent participants. These will allow students to rate each part of the curriculum, including the instructors,
online portions and small group discussions. All of these methods of evaluation taken together will be used to show the
successes and failures of the curriculum in its current form, and can inform what resources need to be applied to it in the
future. Furthermore, it can be used as motivation for recruitment of learners and faculty in future iterations. Administrators
and credentialing organizations will likely find these results useful in judging whether the curriculum should be continued,
discontinued, or even expanded. Finally, results will likely be publishable, and be used by educators at other institutions when
making a decision on whether to implement a similar curriculum.
Potential Resources Available for Evaluation

As mentioned in the prior exercise, the curricular plan includes protected time for a curriculum director and an administrator.
As a current fellow, I have protected time (60% to devote to all of my projects) to set aside as the director, likely needing
several hours per week towards the end of the curriculum to direct the evaluation efforts. The administrator would help
collect and organize results, likely also needing several hours per week, which will then be analyzed by the director and other
faculty members on the team. Statistical support, software, and computers are available at the institution as well. The testing
and satisfaction-based assessments will be available through the online learning management system to students, who will
complete it as part of the curriculum in their own personal facilities with their own personal equipment. In terms of funding,
statistical support from the department will be available at no charge. The learning management system will have been
accounted for in the initial budget of the curriculum, which will be supported by intra-departmental funds. Finally, initial data
from the needs assessment, as well as pre-test assessments will be available for comparison.
Proposed Evaluation Questions

1. At the end of the curriculum, what percentage of learners will be able to define the diagnostic criteria and low risk
criteria for BRUE with >90% accuracy?
2. At the end of the curriculum, what percentage of learners applied the diagnostic criteria and low-risk criteria to
accurately determine a case as low-risk BRUE, non-low-risk BRUE and non-BRUE event in 5/6 practice cases?
3. What was the perceived effectiveness of the curriculum’s online modules and in-person small group discussions?
What did the learners perceive as the major strengths and weaknesses of the curriculum and areas where
improvements can be made? What did learners identify as the most important take-away and least understood point
from each session?
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Relating Evaluation Questions to Curricular Objectives

The first two questions directly apply to curricular objectives demonstrating knowledge and application skills, respectively. The
last group of questions applies to the perceived effectiveness and learner opinions about the curriculum, and will help
determine where efforts need to be on curricular revision. They are all congruent with curricular objectives and therefore, do
not require a change in objectives or evaluation questions.
Proposed Evaluation Design

In terms of design, question 1 and 2 above can be done in the same design. I think the most feasible and rigorous design
would be a single group pretest/posttest design (O1 --- X --- O2). While this does have the disadvantage of not distinguishing
whether the growth was due to natural maturation or other factors and not due to the curriculum, it is also much more
feasible than finding a control group of similar characteristics willing to take two tests. I also believe having a control group
taking the tests without attending the curriculum is depriving them of potential learning that their colleagues are receiving.
For the questions labeled with number 3 above, as the questions relate directly to the leaner experiences and opinions of the
curriculum, a single group posttest only evaluation (X – O) would be appropriate as the questions would be invalid if given
prior to the curriculum or to people who have not used the curriculum.
Proposed Evaluation Methods and Resources Needed

For the first two questions, the most feasible and congruent method of evaluation would be a computer-interactive test
within the already established online learning management system. These questions could easily be tailored into multiple
choice and short answer test questions. The challenge with this method (and any testing method) would be to obtain experts
in subject matter and question writing to make this a meaningful evaluation. These tests could also be given as written tests or
as part of an oral exam, which may allow for a more controlled environment and the ability to explore knowledge and
understanding more thoroughly, but both of these would be more resource-intensive (needing facilities and facilitators),
therefore making them less feasible, at least in the initial run of the curriculum. I think direct observation and performance
audits of patient encounters would also be a higher-level way to evaluate these skills, but much more resource-intensive and
not feasible at the current time.
For the third group of questions, the most feasible method would be through an online questionnaire, also within the learning
management software. It would be easily tailored into a mix of Likert scale and free response questions. More detailed and
rich data could be obtained through interviews, both individual and group, but once again, these methods are less feasible
given the resources needed (facilities, funding and facilitators).
Ethical Concerns
Any questionnaire or interview raises the concern of confidentiality. An online management system will be password
protected and secure, and have the ability to allow certain portions of the evaluation to be anonymous (specifically question
3). Furthermore, responses for question 3 style questions could be batched quarterly to avoid any potential re-identification.
The online system would also allow grades and feedback to be given directly to the learner in a secure way, and it will be
emphasized that these are for formative purposes. For evaluation and research purposes, the design will likely have to receive
IRB approval. The IRB will ensure the confidentiality and consent procedures are appropriate and provide ethical oversight.
Whenever you initiate a new curriculum, there are ethical issues related to access and resources allocation. I would like to
start with a small volunteer cohort and would not deny anyone who would like to volunteer. As the curriculum is
demonstrated as a success, it would be able to garner more resources, allowing it to be available to all faculty. One reason the
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evaluation design was chosen as a single-group was to avoid denying a group of potential learners the chance of utilizing the
curriculum.
Data Collection Process

With the current plan, all of the evaluations will take place as part of the curriculum through the learning management
software. In this way, data collection will be automatic, and completion of the curriculum will require responses to the
evaluations. The administrator will be able to organize the data for analysis. If the evaluation was expanded to include oral
examination or interviews, it would be logistically more difficult to ensure a high response rate as well as be much more
resource intensive. Regardless of the style of evaluation, support from organizational leadership to complete the curriculum
and the evaluations would likely be instrumental in ensuring good response rates.
Data Analysis Plan

For the first two questions, due to the comparative nature of the pre and posttest evaluations, statistical tests of significance
would be needed. In order to ensure statistical rigor, a consultation with a statistician will be required. Specifically, this
consultation would need to start prior to the roll-out in order to ensure adequate power is obtained with the number of initial
learners.
For the third group of questions, descriptive statistics will be used for the Likert scale questions. Qualitative data analysis will
be used for the prompted written responses to identify themes and areas for improvement. No further consultation will be
required due to the curriculum director’s expertise in qualitative analysis.
Proposed Format for Evaluation Reports

The goal of these reports for the first two questions is both to demonstrate growth of the learner after completing the
curriculum (pre/posttests) as well as overall high levels of knowledge/skills/attitudes on the subject matter. Users will receive
an immediate report on their own performance, including which questions were answered correctly and incorrectly, and why
the correct answers are correct. They will also receive information about their improvement from the pre-test. In the future, it
is possible that participants will also be shown the percentage of their colleagues who answered the question correct, but
during the initial roll-out, this information would not yet have been collected. All of this will be through the online
management system. This data will also be collected by the curricular team anonymously and statistically analyzed for
presentation to stakeholders and for publication. This will likely be done in the 1-2 months after the initial cohort of the
curriculum is completed, as it takes time for statistical analysis and organization.
The goal of the reports for the question labeled number 3 is to show satisfaction or dissatisfaction with the curriculum and
identify areas of usefulness and areas to improve. These reports will be organized into a summary showing the mean
satisfaction scores as well as the aforementioned qualitative analysis of written prompts. Reports will be concluded with a
summary of suggested actions to take based on the evaluation. These will be distributed to all stakeholders in the curriculum
to garner further support in its continuation, as well as to the curricular team to plan improvements. Furthermore, it will be
presented in publication. This will likely be done in the 1-2 months after the initial cohort of the curriculum is completed, as it
takes time for statistical analysis and organization.
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References
1. Tieder JS. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk
infants: Executive summary. Pediatrics (Evanston). 2016;137(5)
2. Colombo M, Katz ES, Bosco A, Melzi ML, Nosetti L. Brief resolved unexplained events: Retrospective validation of
diagnostic criteria and risk stratification. Pediatr Pulmonol. 2019;54(1):61-65.
3. Meyer JS, Stensland EG, Murzycki J, Gulen CR, Evindar A, Cardoso MZ. Retrospective application of BRUE criteria to
patients presenting with ALTE. Hosp Pediatr. 2018.
4. Triemstra J. The cost of hospital admission: Brief resolved unexplained events. Pediatric annals. 2017;46(7):e262-
e264.
5. Conroy M, Shannon W. Clinical guidelines: Their implementation in general practice. Br J Gen Pract.
1995;45(396):371-375.
6. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical
experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157(4):408-416
7. Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic
review. J Pediatr. 2013;163(1):94–99.
8. Knowles, M.S. (1984). The adult learner: A neglected species. (3rd edition). Houston: Gulf.
9. Carraccio, C et al. The Pediatric Milestone Project: A Joint Initiative of The Accreditation Council for Graduate Medical
Education and The American Board of Pediatrics,
https://www.acgme.org/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf?ver=2017-07-24-124802-340,
published 2017, accessed 4/2019
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A Proposed Curriculum to

Improve the Practice of

Problem Identification and General Needs Assessment

Health Care Problem Addressed by the Curriculum

Populations Affected by the Problem

Health Care Professionals

Effects of the Problem

Medical Complications from Unnecessary Testing

Table 1: Current and Ideal Approaches to Address the Problem

Description of Difference between Current and Ideal Approaches

Table 2: Knowledge Deficiencies and Correction Strategies

Targeted Needs Assessment

Description of Targeted Learners

Description of the Targeted Learning Environment

Description of the Stakeholders

Residency and Student Educational Leadership

Nursing Faculty and Leadership

AAP and Other Accrediting Bodies

Information That Needs Clarification

The Learning Preferences and Styles of the Targeted Learners

Faculty Familiarity with Different Asynchronous Learning Techniques

Proposal for Initial Needs Assessment

Goals and Objectives

Relation of Goals to Defined Competencies

Proposed Educational Objectives

Relation of Objectives to Goals

Relation of Objectives to Competencies

Example Educational Strategies

Example of Educational Methods that are Learner-Centered or Promote Self-Directed Learning.

Example of Educational Strategies that Promote Practice-Based Learning and Improvement or

Example of Educational Strategies that Promote Professionalism.

Resources and Feasibility of Above Strategies

Proposed Administrative Structure

Barriers to Implementation and Strategies to Overcome Them

Lack of Volunteer Facilitators

Unavailability or Inability to Use an Online Portal

Lack of Availability of a Coordinator

Proposed Implementation Plan

Evaluation and Feedback

Potential Resources Available for Evaluation

Proposed Evaluation Questions

Relating Evaluation Questions to Curricular Objectives

Proposed Evaluation Design

Proposed Evaluation Methods and Resources Needed

Data Collection Process

Data Analysis Plan

Proposed Format for Evaluation Reports

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