title: Identification of Barriers to Pediatric Care in Limited-Resource Settings: A Simulation Study.
abstract: OBJECTIVE
  Eighty percent of the 10 million annual deaths in children aged <5 years in developing countries are estimated to be avoidable, with improvements in education for pediatric emergency management being a key factor. Education must take into account cultural considerations to be effective. Study objectives were: (1) to use simulation to identify factors posing barriers to patient care in limited resource settings (LRS); and (2) to understand how simulations in LRS can affect communication and decision-making processes.
  
  
  METHODS
  A qualitative study was conducted at 17 different sites in 12 developing countries in Asia, Latin America, and Africa. Data from observations of 68 in situ simulated pediatric emergencies were coded for thematic analysis. Sixty-two different "key informants" were interviewed regarding perceived benefit of simulations.
  
  
  RESULTS
  Coding of observations and interviews yielded common themes: impact of culture on team hierarchy, impact of communication and language barriers on situational awareness, systematic emergency procedures, role delineation, shared cognition and resource awareness through simulation, logistic barriers to patient care, and use of recognition-primed decision-making by experienced clinicians. Changes in clinical environments were implemented as a result of simulations.
  
  
  CONCLUSIONS
  Ad hoc teams in LRS face challenges in caring safely for patients; these include language and cultural barriers, as well as environmental and resource constraints. Engaging teams in simulations may promote improved communication, identification of systems issues and latent threats to target for remediation. There may be a role for training novices in use of recognition-primed or algorithmic decision-making strategies to improve rapidity and efficiency of decisions in LRS.
authors.affiliation: Departments of Anesthesiology and Critical Care Medicine, Pediatrics, and nshilko1@jhmi.edu.
authors.forename: Nicole
authors.initials: N
authors.lastname: Shilkofski
authors.affiliation: Departments of Anesthesiology and Critical Care Medicine, Pediatrics, and Health Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Hunt
mesh_terms: D000293:Adolescent; D000349:Africa; D001208:Asia; D002648:Child; D002675:Child, Preschool; D000066491:Clinical Decision-Making; D003144:Communication Barriers; D003198:Computer Simulation; D003906:Developing Countries; D004632:Emergency Medical Services / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic; D007843:Latin America; D008297:Male; D008962:Models, Theoretical; D005791:Patient Care / Q000379:methods / Q000592:standards*; D010348:Patient Care Team / Q000458:organization & administration; D010372:Pediatrics / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D036301:Qualitative Research; D011787:Quality of Health Care / Q000706:statistics & numerical data*