Defining curricular priorities for student-as-teacher programs: A National Delphi Study.

BACKGROUND: "Student-as-Teacher" (SaT) programs have been growing in number to prepare medical students for their teaching roles in residency and beyond, but it remains unknown what content areas should be covered in SaT curricula. AIM: To determine five to ten "essential" content areas for inclusion in SaT curricula using expert opinion. METHODS: Using a three-round Delphi process, moderators iteratively surveyed a panel of 28 medical educators (25 academy directors and three individuals identified as having expertise in undergraduate medical education) representing 25 medical schools in the United States. This "SaT Delphi Working Group" was tasked with rating topics for inclusion in SaT curricula on a 3-point scale (i.e. 1. "essential," 2. "important, but not essential" 3. "not important"). Topics achieving ≥70% consensus as "essential," "important" or "not important" were accepted by the moderators and removed from subsequent rounds. RESULTS: Hundred per cent response rate (n = 28) was achieved for all survey rounds. Five content areas reached consensus as "essential" for inclusion in a SaT curriculum: feedback, bedside teaching and clinical precepting, small-group teaching, case-based teaching and professionalism as a medical educator. CONCLUSION: This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.

Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.

OBJECTIVE: To compare perceptions, goals, and expectations of health care providers and parents regarding parental participation in morning rounds and target specific areas of opportunity for educational interventions. STUDY DESIGN: Semistructured interviews of parents and focus groups of health care providers to learn about their experiences in, goals for, and perceived barriers to successful parental participation in morning rounds. Qualitative methods were used to analyze interview and focus group transcripts. RESULTS: Parents (n = 21) and health care providers (n = 24) participated in interviews and focus groups, respectively. Analyses revealed key areas of agreement between providers and parents regarding goals for rounds when parents are present, including helping parents achieve an understanding of the child's current status and plan of care. Providers and parents disagreed, however, about the nature of opportunities to ask questions. Parents additionally reported a strong desire to provide expert advice about their children and expected transparency from their care team, while providers stated that parental presence sometimes hindered frank discussions and education. CONCLUSIONS: Some agreement in goals for parent participation in morning rounds exists, although there are opportunities to calibrate expectations for both parents and health care providers. Solutions may involve a protocol for orienting parents to morning rounds, focusing on improving communication with parents outside of morning rounds, and the preservation of a forum for providers to have private discussions as a team.

Family participation during intensive care unit rounds: attitudes and experiences of parents and healthcare providers in a tertiary pediatric intensive care unit.

OBJECTIVE: To compare the experiences and attitudes of healthcare providers and parents regarding parental participation in morning rounds, in particular to evaluate for differences in perception of parental comprehension of rounds content and parental comfort with attendance, and to identify subgroups of parents who are more likely to report comfort with attending rounds. STUDY DESIGN: Cross-sectional survey of 100 parents and 131 healthcare providers in a tertiary care pediatric medical/surgical intensive care unit. Descriptive statistics were used to analyze survey responses; univariate and multivariate analyses were performed to compare parent and healthcare provider responses. RESULTS: Of parents, 92% reported a desire to attend rounds, and 54% of healthcare providers reported a preference for parental presence. There were significant discrepancies in perception of understanding between the 2 groups, with healthcare providers much less likely to perceive that parents understood both the format (30% vs 73%, P < .001) and content (21% vs 84%, P < .001) of rounds compared with parents. Analysis of parent surveys did not reveal characteristics correlated with increased comfort or desire to attend rounds. CONCLUSIONS: A majority of parents wish to participate in morning rounds, whereas healthcare provider opinions are mixed. Important discrepancies exist between parent and healthcare provider perceptions of parental comfort and comprehension on rounds, which may be important in facilitating parental presence.

Fluid balance in critically ill children with acute lung injury.

OBJECTIVES: In the Fluid and Catheter Treatment Trial (NCT00281268), adults with acute lung injury randomized to a conservative vs. liberal fluid management protocol had increased days alive and free of mechanical ventilator support (ventilator-free days). Recruiting sufficient children with acute lung injury into a pediatric trial is challenging. A Bayesian statistical approach relies on the adult trial for the a priori effect estimate, requiring fewer patients. Preparing for a Bayesian pediatric trial mirroring the Fluid and Catheter Treatment Trial, we aimed to: 1) identify an inverse association between fluid balance and ventilator-free days; and 2) determine if fluid balance over time is more similar to adults in the Fluid and Catheter Treatment Trial liberal or conservative arms. DESIGN: Multicentered retrospective cohort study. SETTING: Five pediatric intensive care units. PATIENTS: Mechanically ventilated children (age≥1 month to <18 yrs) with acute lung injury admitted in 2007-2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fluid intake, output, and net fluid balance were collected on days 1-7 in 168 children with acute lung injury (median age 3 yrs, median PaO2/FIO2 138) and weight-adjusted (mL/kg). Using multivariable linear regression to adjust for age, gender, race, admission day illness severity, PaO2/FIO2, and vasopressor use, increasing cumulative fluid balance (mL/kg) on day 3 was associated with fewer ventilator-free days (p=.02). Adjusted for weight, daily fluid balance on days 1-3 and cumulative fluid balance on days 1-7 were higher in these children compared to adults in the Fluid and Catheter Treatment Trial conservative arm (p<.001, each day) and was similar to adults in the liberal arm. CONCLUSIONS: Increasing fluid balance on day 3 in children with acute lung injury at these centers is independently associated with fewer ventilator-free days. Our findings and the similarity of fluid balance patterns in our cohort to adults in the Fluid and Catheter Treatment Trial liberal arm demonstrate the need to determine whether a conservative fluid management strategy improves clinical outcomes in children with acute lung injury and support a Bayesian trial mirroring the Fluid and Catheter Treatment Trial.

Head computed tomography scanning during pediatric neurocritical care: diagnostic yield and the utility of portable studies.

BACKGROUND: We report our use of portable head computed tomography (CT) and the diagnostic yield and radiation dose from head CT in the pediatric intensive care unit (PICU). METHODS: 204 PICU patients underwent head CT during 2008-2009. Therapeutic interventions and resource intensity during CT were categorized. Severity of illness was summarized using the pediatric risk of mortality (PRISM-III) model. Estimates of patient radiation dose were based on dose measurements made in four anthropomorphic head phantoms. RESULTS: 242 (62%) out of 391 head CT studies were portable. New pathology was identified on 80 (40%) scans. CT findings prompted a change in management in 46 (23%) patients; 25 of these resulted in life-extending treatments and 21 had forgoing of life-sustaining treatments within 24 hours. 26 patients with PRISM score greater than 30% underwent CT; 23 (88%) of these were portable. More portable versus fixed examinations were performed in patients requiring extracorporeal membrane oxygenation, inhaled nitric oxide, high levels of positive end expiratory pressure, and those with high vasopressor scores (P < 0.05). Estimated patient dose from portable CT was 83 ± 6 mGy compared to 72 ± 5 mGy for patients imaged on a fixed scanner (P < 0.0001). CONCLUSION: Two-thirds of CT scans obtained in the PICU were portable because of patients' intensity of therapy and illness severity. Portable CT showed major new pathology in greater than 1/3 and led to a change in management in 1/4 of higher acuity patients scanned. The estimated radiation dose from portable CT is within the current national guidelines.