Newborn Pulse Oximetry Screening at a Community Hospital: An 8-Year Experience.

OBJECTIVES: To evaluate newborn pulse oximetry screening (POS) outcomes at a large community hospital and the impact of the recommended revised POS algorithm. METHODS: A retrospective cohort study was performed to evaluate the results of POS in the well-infant nursery between 2012 and 2020. The POS results were obtained from an electronic platform. Chart review was completed for newborns with failed screens. The recommended revision to POS, no second rescreen, was applied to the data to evaluate screening outcomes. RESULTS: Of the total 65 414 infants admitted to the well-infant nursery during this 8-year period, >99% (n = 64 780) received POS. Thirty-one infants failed POS (4.6 per 10 000 screened). All infants who failed POS were found to have a disorder, with 12 (39%) having critical congenital heart disease (CCHD), 9 (29%) having non-CCHD requiring further follow-up, and 10 (32%) having noncardiac conditions. One false-negative screen result was identified through the Maryland Department of Health Newborn Screening Follow-up Program. The positive predictive value of POS for those screened was 39% for CCHD, with a specificity of 99.97%. Eliminating the second rescreen in the POS algorithm would have resulted in an additional 5 newborns without CCHD failing POS, increasing the false-positive rate from 0.03% to 0.04%. CONCLUSIONS: POS is an effective tool for identifying CCHD and secondary conditions. POS was successfully implemented with few missed screens and was highly specific. Elimination of the second rescreen in the pulse oximetry algorithm would have resulted in a minimal increase in false-positive results and faster evaluation of newborns with CCHD.

Strategies for Teaching Medical Students: A Faculty Development Workshop for Pediatric Preceptors in the Community Setting.

Introduction: An increasing number of medical students complete clerkships outside of traditional university-affiliated medical centers despite little faculty development geared specifically for the community preceptor. Moreover, the community setting presents a unique set of challenges, including fewer educational resources, greater expectation of clinical productivity, and a wide geographic distribution of preceptors. Methods: This 90-minute workshop provided pediatric community preceptors with effective teaching strategies that could be used in their setting. First, participants identified opportunities and challenges for medical student education in the community setting. Then, participants discussed approaches to strengthen the students' learning experience in small-group breakout sessions. Finally, workshop leaders emphasized specific teaching resources and methods to empower participants. Results: This workshop was presented at three national pediatric conferences and had at least 57 participants (40 total respondents). Over the three iterations, participants consistently rated this workshop as highly effective and engaging, with the small-group breakout session rated most engaging. Over time, modifications to the workshop included lengthening breakout sessions, shortening didactic materials to enhance audience discussion, and expanding content to include the outpatient setting. In later iterations, participants identified a specific medical education challenge at their institution and committed to using a technique they learned from the workshop. Discussion: This workshop targeted inpatient and outpatient pediatric preceptors to address the community-based faculty development gap. After completing the workshop, community preceptors can enhance the medical education experience by optimizing invaluable opportunities in the community setting and applying targeted strategies and resources.

Pediatric Resident Training in the Community Hospital Setting: A Survey of Program Directors.

BACKGROUND AND OBJECTIVE: The role of a hospitalist differs in a community hospital (CH) compared to a university/children's hospital. Residents are required to practice in a variety of relevant clinical settings, but little is known about current trends regarding pediatric resident training in different hospital settings. This study explores CH rotations including their value for resident training, characteristics, benefits, and drawbacks. This study also seeks to define "community hospital." METHODS: Authors conducted an online cross-sectional survey of pediatric residency program directors distributed by the Association of Pediatric Program Directors. The survey was developed and revised based on review of the literature and iterative input from experts in pediatric resident training and CH medicine. It assessed residency program demographics, availability of CH rotations, value of CH rotations, and their characteristics including benefits and drawbacks. RESULTS: Response rate was 56%. CH rotations were required at 24% of residency programs, available as an elective at 46% of programs, and unavailable at 48% of programs. Residency program directors viewed these rotations as valuable for resident training. CH rotations were found to have multiple benefits and drawbacks. Definitions of "community hospital" varied and can be categorized according to positive or negative characteristics. CONCLUSIONS: Resident rotations at a CH provide valuable learning opportunities with multiple potential benefits that should be weighed against drawbacks in the context of a residency program's curriculum. There are many characteristics that potentially distinguish CH from university/children's hospitals.

Facilitating the Timely Discharge of Well Newborns by Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Discharges are a key driver of hospital throughput. Our pediatric hospitalist team sought to improve newborn nursery throughput by increasing the percentage of newborns on our service with a discharge order by 11 am. We hypothesized that implementing a discharge checklist would result in earlier discharge times for newborns who met discharge criteria. METHODS: We identified barriers to timely discharge through focus groups with key stakeholders, chart reviews, and brainstorming sessions. We subsequently created and implemented a discharge checklist to identify and address barriers before daily rounds. We tracked mean monthly discharge order times. Finally, we performed chart reviews to determine causes for significantly delayed discharge orders and used this information to modify rounding practices during a second plan-do-study-act cycle. RESULTS: During the 2-year period before the intervention, 24% of 3224 newborns had a discharge order entered by 11 am. In the 20 months after the intervention, 39% of 2739 newborns had a discharge order by 11 am, a 63% increase compared with the baseline. Observation for group B Streptococcus exposure was the most frequent reason for a late discharge order. CONCLUSIONS: There are many factors that affect the timely discharge of well newborns. The development and implementation of a discharge checklist improved our ability to discharge newborns on our pediatric hospitalist service by 11 am. Future studies to identify nonphysician barriers to timely newborn discharges may lead to further improvements in throughput between the labor and delivery and maternity suites units.

Educating pediatric residents about breastfeeding: evaluation of 3 time-efficient teaching strategies.

BACKGROUND: Previously reported breastfeeding curricula for residents have combined different teaching methods, have focused on knowledge and attitudes, and have been time-intensive. OBJECTIVE: This study aimed to evaluate 3 time-efficient breastfeeding curricula for effectiveness in regard to pediatric residents' knowledge, confidence, and skills in managing a simulated breastfeeding scenario. METHODS: First-year pediatric residents during their 4-week community hospital newborn nursery rotation were consecutively assigned to 1 of 3 groups. Group 1 shadowed an International Board Certified Lactation Consultant (IBCLC) for 1 hour; group 2 watched a 25-minute case-based breastfeeding DVD; and group 3 observed a 3-hour prenatal parent breastfeeding class (CLS). Residents were assessed by (1) a pretest and posttest evaluating their breastfeeding knowledge and confidence, and (2) a clinical skills scenario managing a breastfeeding standardized patient (SP). RESULTS: Thirty-nine pediatric residents participated in the study (11 in IBCLC, 16 DVD, 12 CLS) over a 1-year period. All groups significantly improved their knowledge scores and confidence in managing breastfeeding problems, with the IBCLC group showing more improvement in knowledge than the other groups (P = .02) and a higher rating of their teaching method (P = .01). All groups performed well on the SP clinical skills scenario, with no significant difference between groups. CONCLUSION: All 3 teaching methods were time-efficient and produced important gains in knowledge and confidence, with residents in the IBCLC group demonstrating greatest improvement in knowledge and a higher rating of their teaching method. Our study provides support for 3 methods of teaching residents breastfeeding management and demonstrates that IBCLCs are well-received as interprofessional educators.

Observation of resident clinical skills: outcomes of a program of direct observation in the continuity clinic setting.

OBJECTIVE: To assess the feasibility of a new multi-institutional program of direct observation and report what faculty observed and the feedback they provided. METHODS: A program of direct observation of real patient encounters was implemented in 3 pediatric residency programs using a structured clinical observation (SCO) form to document what was observed and the feedback given. Outcome variables included the number of observations made, the nature of the feedback provided, resident attitudes about direct observation before and after implementation, and the response of the faculty. RESULTS: Seventy-nine preceptors and 145 residents participated; 320 SCO forms were completed. Faculty provided feedback in 4 areas: content, process of the encounter, patient-centered attitudes and behaviors, and interpersonal skills. Feedback was 85% specific and 41% corrective. Corrective feedback was most frequent for physical examination skills. After program implementation, residents reported an increase in feedback and a decrease in discomfort with direct observation; in addition, they agreed that direct observation was a valuable component of their education. Participation rates among faculty were high. CONCLUSIONS: Direct observation using SCOs results in timely and specific feedback to residents about behaviors rarely observed in traditional precepting models. Resident competency in these clinical skill domains is critical for assessing, diagnosing, and managing patients. The SCO methodology is a feasible way to provide formative feedback to residents about their clinical skills.

Decreasing variability in faculty ratings of student case presentations: a faculty development intervention focusing on reflective practice.

BACKGROUND: Faculty perceptions of medical student knowledge are often based on case presentations, but their assessment of student performance can vary significantly based on content, presentation skill, and interpersonal characteristics. PURPOSE: To determine if a brief faculty development intervention could significantly decrease (>or= 20%) faculty members' variability in rating student case presentations in the ambulatory setting. METHODS: During the 1998-99 academic year, we videotaped 10 third-year medical students during one well-child presentation. Seven general pediatric faculty rated the videotapes using a validated scoring instrument measuring content: History of Present Illness (HPI), Past Medical History, and Physical Exam (PE); and communication skill: Precision of Language, Fluency, and Economy. Baseline ratings were from June to September 1999 and then repeated in October to November 2000 following a workshop where faculty reflected on the rating process and decreasing rating variance. The change in mean faculty ratings of the student's overall performance and for each item and the change in the mean difference in standard deviation before and after the workshop were analyzed. RESULTS: Internal consistency of the scoring instrument using Cronbach's alpha was 0.88. The mean faculty rating for overall presentation performance and the PE did not significantly change after the workshop, whereas for all other items it did. The mean standard deviation of faculty ratings decreased significantly for the overall performance and all other items except HPI. CONCLUSION: Despite using a validated scoring instrument to rate student case presentations significant variability exists among faculty, with rating inflation likely. A brief faculty development intervention using "reflection-on-action" was associated with more congruent ratings in the short term.