Child Abuse Recognition Training for Prehospital Providers Using Deliberate Practice.

BACKGROUND: In most states, prehospital professionals (PHPs) are mandated reporters of suspected abuse but cite a lack of training as a challenge to recognizing and reporting physical abuse. We developed a learning platform for the visual diagnosis of pediatric abusive versus non-abusive burn and bruise injuries and examined the amount and rate of skill acquisition. METHODS: This was a prospective cross-sectional study of PHPs participating in an online educational intervention containing 114 case vignettes. PHPs indicated whether they believed a case was concerning for abuse and would report a case to child protection services. Participants received feedback after submitting a response, permitting deliberate practice of the cases. We describe learning curves, overall accuracy, sensitivity (diagnosis of abusive injuries) and specificity (diagnosis of non-abusive injuries) to determine the amount of learning. We performed multivariable regression analysis to identify specific demographic and case variables associated with a correct case interpretation. After completing the educational intervention, PHPs completed a self-efficacy survey on perceived gains in their ability to recognize cutaneous signs of abuse and report to social services. RESULTS: We enrolled 253 PHPs who completed all the cases; 158 (63.6%) emergency medical technicians (EMT), 95 (36.4%) advanced EMT and paramedics. Learning curves demonstrated that, with one exception, there was an increase in learning for participants throughout the educational intervention. Mean diagnostic accuracy increased by 4.9% (95% CI 3.2, 6.7), and the mean final diagnostic accuracy, sensitivity, and specificity were 82.1%, 75.4%, and 85.2%, respectively. There was an increased odds of getting a case correct for bruise versus burn cases (OR = 1.4; 95% CI 1.3, 1.5); if the PHP was an Advanced EMT/Paramedic (OR = 1.3; 95% CI 1.1, 1.4) ; and, if the learner indicated prior training in child abuse (OR = 1.2; 95% CI 1.0, 1.3). Learners indicated increased comfort in knowing which cases should be reported and interpreting exams in children with cutaneous injuries with a median Likert score of 5 out of 6 (IQR 5, 6). CONCLUSION: An online module utilizing deliberate practice led to measurable skill improvement among PHPs for differentiating abusive from non-abusive burn and bruise injuries.

Sudden cardiac arrests, automated external defibrillators, and medical emergency response plans in Tennessee high schools.

OBJECTIVES: Schools are important public locations of sudden cardiac arrest (SCA), and the American Heart Association (AHA) recommends medical emergency response plans (MERPs), which may include an automated external defibrillator (AED) in schools. The objective of this study was to determine the incidence of SCA and the prevalence of AEDs and MERPs in Tennessee high schools. METHODS: Tennessee Secondary School Athletic Association member schools were surveyed regarding SCA on campus within 5 years, AED presence, and MERP characteristics. RESULTS: Of 378 schools, 257 (68%) completed the survey. There were 21 (5 student and 16 adult) SCAs on school grounds, yielding a 5-year incidence of 1 SCA per 12 high schools. An AED was present at 11 of 21 schools with SCA, and 6 SCA victims were treated with an AED shock. A linear increase in SCA frequency was noted with increasing school size (<500 students: 3.3% incidence, 500-1000: 6.5%, 1000-1500: 12.5%, ≥1500: 18.2%; P = 0.003). Of 257 schools, 71% had an MERP, 48% had an AED, and only 4% were fully compliant with AHA recommendations. Schools with a history of SCA were more likely to be compliant (19% vs. 3%, P = 0.011). CONCLUSIONS: The 5-year incidence of SCA in Tennessee high schools is 1 in 12, but increases to 1 in 7 for schools with more than 1000 students. Compliance with AHA guidelines for MERPs is poor, but improved in schools with recent SCA. Future recommendations should encourage the inclusion of AED placement in schools with more than 1000 students.

Analysis of parental and nurse weight estimates of children in the pediatric emergency department.

OBJECTIVE: To evaluate the accuracy of parent and triage nurse estimates of children's weights in the pediatric emergency department. METHODS: A convenience sample of parents was surveyed before triage regarding their child's chief complaint, when and where the child was last weighed, and an estimate of their child's weight. Children unable to be weighed or with possible dehydration or external orthopedic devices were excluded. Nurses also estimated children's weights before weighing them and were blinded to parent estimates. All nurses were experienced in the department, had participated in a triage course, and had completed a background survey. RESULTS: Nine hundred forty-two patients presenting to pediatric emergency department triage were enrolled, resulting in 812 surveys. Parents were more accurate at weight estimation than nurses, with 79% of parents and 83% of legal guardians estimating weights within 10%. Only 55% of nurse estimates were within 10%. Parents and nurses tended to underestimate patients' weights (P < 0.0001). Parent estimates were not affected by a child's age or sex or the location the child was last weighed (P > 0.05). Accuracy of nurse estimates was not related to nurse education or experience (P > 0.05). Parent estimates of weight were more accurate than nurse estimates 74.6% of the time. CONCLUSIONS: Parents were more accurate at estimating children's weights than triage nurses but were within 10% of the children's actual weights only 79% of the time. Nurse estimates were highly inaccurate. Other methods to estimate patient weights should be used when actual patient weights are unobtainable.

The effect of diagnosis-specific computerized discharge instructions on 72-hour return visits to the pediatric emergency department.

OBJECTIVE: The number of patients returning to the pediatric emergency department (PED) within 72 hours of discharge is frequently cited as a benchmark for quality patient care. The purpose of this study was to determine whether the introduction of diagnosis-specific computer-generated discharge instructions would decrease the number of medically unnecessary return visits to the PED. METHODS: A retrospective chart review of patients who returned to the PED within 72 hours of discharge was performed. Charts were reviewed from 2 comparable periods: September 2004 to February 2005, when handwritten discharge instructions were issued to each patient, and September 2005 to February 2006, when each patient received computer-generated diagnosis-specific discharge instructions. The patient's age, primary care provider, insurance status, chief complaint, vital signs, history, physical examination, plan of care, and diagnosis at each visit were recorded. Cases were excluded if the patient left against medical advice or without being seen, was admitted to the hospital on the first visit, or had incomplete or missing records. The medical necessity of the return visit was rated as "yes," "no," or "indeterminate" based on review of the visit noting reason for return, history and physical examination, diagnosis, and interventions or changes in the initial care plan. RESULTS: Of all return visits to the PED within 72 hours of discharge, 13% were deemed unnecessary for patients receiving handwritten instructions compared with 15% for patients receiving computer-generated instructions (P = 0.5, not significant). For each additional year of age, the return visit was 1.07 times as likely to be medically appropriate (95% confidence interval, 1.03-1.12; P = 0.002). Patients who returned to the PED more than once were 2.69 times more likely to have a medically appropriate visit as were those with only 1 return visit (95% confidence interval, 0.95-7.58; P = 0.062). CONCLUSIONS: Computer-generated diagnosis-specific discharge instructions do not decrease the number of medically unnecessary repeat visits to the PED.

Pediatric emergency medicine fellowship research curriculum: a survey of fellowship directors.

OBJECTIVE: To determine how pediatric emergency medicine (PEM) fellowship directors organize research training and to identify factors believed to be associated with successful research training. METHODS: A 16-question survey study of PEM fellowship directors. RESULTS: Of the 58 fellowship directors surveyed, 39 (67%) responded. Of 38 programs, PEM faculty from 20 (53%) served as research mentors for PEM fellows. The mean percentage of PEM faculty who had performed peer-review funded research was 26%. The mean number of trainee research months was 10.9 for 3 years. Of these research months, 93% were not protected (included clinical work hours). Only 5 programs provided some completely protected research months (months without any clinical work hours), and none of these were scheduled in blocks of greater than 3 consecutive months. Most (56%) of these research months were scheduled during the third year of training. The most likely explanations of the fellow successfully becoming research competent were eagerness to apply self and number of research months during training. Least likely explanations were faculty with peer-reviewed funded grants and blocks of research time. Thirty-five fellowship directors (90%) believed that upon completion of the training, their fellows would be research competent. CONCLUSIONS: Besides the fellow's eagerness to apply self, scheduling adequate time for research was reported as a highly important factor in achieving research competency among PEM fellows. Providing protected (no clinical responsibilities) research months to fellows and arranging more opportunities for PEM faculty to serve as research mentors may maintain or possibly improve the likelihood of PEM fellows to becoming research competent.

A pilot trial comparing cerebral perfusion pressure-targeted therapy to intracranial pressure-targeted therapy in children with severe traumatic brain injury.

OBJECT: The authors sought to compare cerebral perfusion pressure (CPP)- with intracranial pressure (ICP)-targeted therapy in children with severe traumatic brain injury (TBI). METHODS: A randomized controlled trial was developed to assess CPP and ICP therapies in 17 children (range 15 months-15 years of age) with poststabilization Glasgow Coma Scale (GCS) scores of less than or equal to 8 who were admitted to a pediatric intensive care unit at a Level I trauma center. Goals in the ICP group were to maintain ICP lower than 20 mm Hg and CPP higher than 50 mm Hg. In the CPP group, goals were to maintain CPP higher than 70 mm Hg for patients at least 2 years old and higher than 60 mm Hg for patients younger than 2 years of age. The study outcomes were death or functional outcome at 1 year postinjury. The median GCS scores in the CPP group (12 patients) and the ICP group (five patients) were 6 and 7, respectively. In the CPP group, two patients died, one was lost to follow up, four were unimpaired, and five had mild impairment. In the ICP group, all patients survived; one was lost to follow up, two had mild impairment, and two had hemiparesis and moderate impairment. There were four unimpaired survivors in the CPP arm compared with none in the ICP arm (p = 0.08). CONCLUSIONS: The CPP method appears to be safe, although this feasibility study does not establish that the CPP therapy is superior to ICP therapy.