Perspectives on preparedness for pediatric emergencies after residency: A needs assessment.

Background: General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design. Methods: In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance. Results: The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms. Conclusions: This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Continuing Education Evaluations of an Internal Medicine and a Pediatric Podcast.

INTRODUCTION: This study aimed to characterize practitioners who use podcasts as a form of continuing education (CE), evaluate attitudes regarding podcasting as a medium for CE, and assess intended practice change after listening to podcasts for CE. METHODS: We examined CE data from a mandatory postpodcast evaluation collected between February 2021 and August 2021 for two free podcasts. We analyzed linked episode data containing podcast downloads. RESULTS: Listeners downloaded 972,691 episodes and claimed 8182 CE credits (less than 1% of total downloads) over 7 months. CE credit was claimed by physicians, physician assistants, nurses, and pharmacists. Most listeners claiming CE credit were not affiliated with an academic institution. Motivation for listening to episodes included a topic of interest, relevance to a patient, and a topic of less comfort. Of individuals obtaining CE, 98% intended to implement change after listening. DISCUSSION: Although only a small number of podcast listeners claim CE credit, those who claim credit represent a diverse and interprofessional audience. Listeners select podcasts to fill self-identified learning needs. Overwhelmingly, listeners report podcast CE changes intended practice. Podcasts may be an effective modality for CE and practice change; further research should focus on facilitators and barriers to CE uptake and on patient health outcomes.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

BACKGROUND: Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied. OBJECTIVES: This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians. STUDY DESIGN: Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment. RESULTS: A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure. CONCLUSIONS: Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.

"What Do You Want to Learn or Work on Today?": Benefits and Barriers to Asking Residents for Self-identified Learning Goals.

BACKGROUND: In the emergency department (ED), residents and attendings may have a short-term relationship, such as a single shift. This poses challenges to learner assessment, instructional strategy selection, and provision of substantive feedback. We implemented a process for residents to identify goals for ED shifts; characterized residents' goals; and determined how goal identification affected learning, teaching, and feedback. METHODS: This was an observational study in a large, tertiary pediatric ED using mixed methods. Residents were asked to identify learning goals for each shift and were asked postshift if they had identified, accomplished, and/or received feedback on these goals. Goals were categorized by Accreditation Council for Graduate Medical Education Core Competencies. Predictors of goal identification, accomplishment, and receipt of feedback were determined. Residents and attendings were interviewed about their experiences. RESULTS: We collected 306 end-of-shift surveys (74% response rate) and 358 goals and conducted 29 interviews. We found that: 1) Goal setting facilitated perceived learning. Residents identified goals 54% of the time. They accomplished 89% of and received feedback on 76% of goals. 2) Residents' perceived weaknesses, future practice settings, and available patients informed their goals. Most goals mapped to patient care (59%) or medical knowledge (37%) competencies. 3) Goal identification helped attendings determine residents' needs. 4) Ideal goals were specific and achievable. 5) Common barriers were busyness of the ED and difficulty creating goals. Residents were less likely to identify goals (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.41 to 0.94) and receive feedback on busy evening shifts (OR = 0.19, 95% CI = 0.10 to 0.37) and were most likely to receive feedback overnight (OR = 3.66, 95% CI = 1.87 to 7.14). CONCLUSIONS: Asking residents to identify goals for ED shifts as an instructional strategy facilitated perceived learning, goal accomplishment, and receipt of feedback. Resident-driven goal identification is a simple and effective instructional strategy that physicians can incorporate into their precepting in the ED.

Clinical Experience in a Community Setting During Pediatric Emergency Medicine Fellowship Training.

OBJECTIVES: The aim of this study is to explore current community emergency department (ED) experiences available to pediatric emergency medicine (PEM) trainees and estimate the proportion of graduates taking positions that involve working in a community ED setting. METHODS: We conducted an e-mail-based survey among PEM fellowship directors and assistant directors. RESULTS: There were 55 program director respondents (74% response rate). Thirty-one percent of the surveyed PEM fellowship programs provide training exposure to a community ED setting. Twenty-nine percent of the surveyed programs reported that 25% to 49% of graduating trainees accepted positions that involve working in a community hospital ED setting, 13% responded 50% to 74%, and 4% report 75% to 100% from 2012 to 2016. CONCLUSIONS: There is an overall paucity of a dedicated community rotation for PEM trainees, yet many graduates are seeking employment in community-based EDs. Because the need for community-based PEM physicians continues to rise and to adequately prepare the PEM workforce, PEM fellowship training should consider a curriculum that includes community-based ED clinical experiences.

Influence of simulation on electronic health record use patterns among pediatric residents.

Objective: Electronic health record (EHR) simulation with realistic test patients has improved recognition of safety concerns in test environments. We assessed if simulation affects EHR use patterns in real clinical settings. Materials and Methods: We created a 1-hour educational intervention of a simulated admission for pediatric interns. Data visualization and information retrieval tools were introduced to facilitate recognition of the patient's clinical status. Using EHR audit logs, we assessed the frequency with which these tools were accessed by residents prior to simulation exposure (intervention group, pre-simulation), after simulation exposure (intervention group, post-simulation), and among residents who never participated in simulation (control group). Results: From July 2015 to February 2017, 57 pediatric residents participated in a simulation and 82 did not. Residents were more likely to use the data visualization tool after simulation (73% in post-simulation weeks vs 47% of combined pre-simulation and control weeks, P <. 0001) as well as the information retrieval tool (85% vs 36%, P < .0001). After adjusting for residents' experiences measured in previously completed inpatient weeks of service, simulation remained a significant predictor of using the data visualization (OR 2.8, CI: 2.1-3.9) and information retrieval tools (OR 3.0, CI: 2.0-4.5). Tool use did not decrease in interrupted time-series analysis over a median of 19 (IQR: 8-32) weeks of post-simulation follow-up. Discussion: Simulation was associated with persistent changes to EHR use patterns among pediatric residents. Conclusion: EHR simulation is an effective educational method that can change participants' use patterns in real clinical settings.

Resident perspectives on professionalism lack common consensus.

STUDY OBJECTIVE: We sought to characterize and understand the residents' perspective on how professionalism develops through pediatric emergency medicine experiences. METHODS: Qualitative methods (freelisting--listing words associated with professionalism--and semistructured interviews) were conducted with senior emergency medicine and pediatric residents about their experiences rotating in the emergency department of a large, urban, tertiary care, freestanding children's hospital. All senior residents were eligible, with purposive sampling to maximize demographic variability. Saliency (importance) of words was analyzed with Smith S scores and consensus analysis. Interviews were conducted until content saturation was achieved; transcripts were coded by independent investigators to reach thematic consensus. RESULTS: Twenty-five interviews (36% emergency, 64% pediatrics) were conducted. Common words associated with professionalism were "respect," "compassion," "empathy," and "integrity"; however, residents did not share a common consensus. The framework for how residents described the development of their professionalism includes observations, interactions, and environment. Examples include resident observation of role models; interactions with patients, families, and coworkers; self-reflection; and the unique environment of the ED. Residents believed that role modeling was the most influential factor. Few reported receiving sufficient observation by attending physicians during their interactions with patients and most reported receiving little direct feedback on their professionalism. Residents' descriptions of professionalism crossed multiple Accreditation Council for Graduate Medical Education (ACGME) competencies. CONCLUSION: Residents displayed high variability in their understanding of professionalism, which was frequently at variance with the corresponding ACGME competency definition. The resident perspective and understanding of professionalism may usefully inform refinements in ACGME milestones and entrustable professional activities.

Predictive value of weight-for-age to identify overweight children.

OBJECTIVE: The objective was to assess the predictive value of weight-for-age to identify overweight children and adolescents in the unusual research or public health situations where height is not available to calculate BMI. RESEARCH METHODS AND PROCEDURES: Data from the National Health and Nutrition Examination Survey 1999 to 2004 were used to calculate the sensitivity, specificity, and positive and negative predictive values of selected weight-for-age cut-off points to identify overweight children and adolescents (as defined by BMI >or=95th percentile). Positive and negative predictive values are dependent on prevalence and are reported here for this study population only. RESULTS: The 50th and 75th weight-for-age percentiles had good sensitivity (100% and 99.6%, respectively), but poor positive predictive value (23.7% and 37.0%, respectively), while the 95th and 97th percentiles had reasonable positive predictive value (80.3% and 91.5%, respectively), but limited sensitivity (82.0% and 66.7%, respectively) to identify overweight subjects. The properties of weight-for-age percentiles to identify overweight subjects differed between sex, age, and race/ethnicity but remain within a relatively narrow range. DISCUSSION: No single weight-for-age cut-off point was found to identify overweight children and adolescents with acceptable values for all properties and, therefore, cannot be used in the clinical setting. Furthermore, the positive predictive values reported here may be lower in populations with a lower prevalence of obesity. However, in unusual research or public health situations where height is not available, such as existing databases, weight-for-age percentiles may be useful to target limited resources to groups more likely to include overweight children and adolescents than the general population.

Tick paralysis: atypical presentation, unusual location.

We present 2 unrelated cases of tick paralysis presenting within a 2-month period in the greater Philadelphia region, a geographic area in which this disease is highly unusual. Our first patient demonstrated early onset of prominent bulbar palsies, an atypical presentation. Our second patient, residing in a nearby but distinct community, presented with ascending paralysis 2 months after the first. The atypical presentation of our first patient and the further occurrence within a few months of a second patient, both from the Northeastern United States where this diagnosis is rarely made, suggest the need to maintain a high index of suspicion for this disease in patients presenting with acute onset of cranial nerve dysfunction or muscle weakness. Through simple diagnostic and therapeutic measures (ie, careful physical examination to locate and remove the offending tick), misdiagnosis and unnecessary morbidity can be avoided.

Early detection of imperforate hymen prevents morbidity from delays in diagnosis.

OBJECTIVE: Although it is detectable at all ages through inspection of the external genitalia, imperforate hymen (IH) is a diagnosis that is missed commonly. We hypothesized that children with late diagnoses (predefined as > or =8 years of age, chosen to reflect the timing of normal menarche) would be more likely to be symptomatic, undergo more diagnostic testing, and lack appropriate documentation in their medical records, compared with children with earlier diagnoses (ie, <8 years of age). METHODS: All patients with IH were identified through searches of 3 hospital databases with International Classification of Diseases, Ninth Revision, codes. The medical records of eligible subjects were reviewed by a single, blinded researcher. Comparisons were made between children diagnosed at younger versus older ages. RESULTS: A bimodal distribution of age at diagnosis was demonstrated; 43% (n = 10) of girls were diagnosed at <8 years of age, and 57% (n = 13) were diagnosed at > or =8 years of age. Among older girls, 100% were symptomatic (abdominal pain and/or urinary symptoms; duration of symptoms: 1-120 days), whereas 90% of cases in the younger group were detected incidentally. Documentation was lacking for breast development (77%), pubic hair development (69%), and menstrual history (46%) among the older girls. Older children were more likely to present symptomatically (odds ratio: 42.0; 95% confidence interval: 3.1-1965.7) and to undergo ancillary testing (odds ratio: 20.3; 95% confidence interval: 1.6-983.1). CONCLUSIONS: Two distinct populations of girls with IH exist, ie, those diagnosed without symptoms at a young age and those not diagnosed until >8 years of age. By incorporating an examination of the external genitalia into their routine practice, clinicians caring for children can prevent the significant delays in diagnosis, misdiagnosis, and morbidity associated with the latter group.

A randomized, clinical trial of a home safety intervention based in an emergency department setting.

OBJECTIVE: To assess the effectiveness of an emergency department (ED)-based home safety intervention on caregivers' behaviors and practices related to home safety. METHODS: We conducted a randomized, clinical trial of 96 consecutive caregivers of children who were younger than 5 years and presented to an urban pediatric ED for evaluation of an acute unintentional injury sustained in the home. After completing a structured home safety questionnaire via face-to-face interview, caregivers were randomly assigned to receive either comprehensive home safety education and free safety devices or focused, injury-specific ED discharge instructions. Participants were contacted by telephone 2 months after the initial ED visit for repeat administration of the safety questionnaire. The pretest and posttest questionnaires were scored such that the accrual of points correlated with reporting of safer practices. Scores were then normalized to a 100-point scale. The overall safety score reflected performance on the entire questionnaire, and the 8 category safety scores reflected performance in single areas of home injury prevention (fire, burn, poison, near-drowning, aspiration, cuts/piercings, falls, and safety device use). The main outcome was degree of improvement in safety practices as assessed by improvement in safety scores. RESULTS: The intervention group demonstrated a significantly higher average overall safety score at follow-up than the control group (73.3% +/- 8.4% vs 66.8% +/-11.1) and significant improvements in poison, cut/piercing, and burns category scores. Caregivers in the intervention group also demonstrated greater improvement in reported use of the distributed safety devices. CONCLUSIONS: This educational and device disbursement intervention was effective in improving the home safety practices of caregivers of young children. Moreover, the ED was used effectively to disseminate home injury prevention information.

Poisoning prevention education during emergency department visits for childhood poisoning.

OBJECTIVE: Childhood poisoning represents a major public health problem that can be prevented through educational efforts. Commonly, young children experiencing a first poisoning episode will have a second occurrence. The aim of this study is to assess whether caretakers of children evaluated in an emergency department for acute poisoning exposure recall receiving poisoning prevention education as part of the medical encounter. METHODS: Consecutive poisoning exposures reported to a regional Poison Control Center concerning children under the age of 6 years were identified. Inclusion criteria were an emergency department referral and subsequent discharge. Within 10 days of emergency department visit, a single trained interviewer administered by telephone a scripted questionnaire concerning the provision of poisoning prevention education. Poison control center logs were reviewed for demographic and treatment data. RESULTS: Of 102 eligible subjects, 77 families were contacted and 75 participated. The median age of poison exposure was 2 years; 45% were male. Seventy-three percent (95% CI: 61% to 83%) of caregivers reported receiving no poisoning prevention education. Among the minority receiving some information, only 25% received verbal instruction. Caregivers of children treated in urban academic centers were more likely to recall prevention education than those treated at suburban and rural hospitals (RR = 5.4; 1.8 to 16.2). Caregivers of children treated at specialized children's hospitals were more likely recall prevention education than general hospitals (RR = 5.3; 1.6 to 17.7). CONCLUSION: Emergency department personnel are missing a potentially important opportunity to provide poisoning prevention education to families of children at high risk for repeat occurrence.

Mild traumatic brain injury in children: practice guidelines for emergency department and hospitalized patients. The Trauma Program, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine.

Mild traumatic brain injury (MTBI) is a frequent occurrence in children. Current practice in treating such injuries varies in terms of evaluative studies, length of observation, need for inpatient hospitalization, sports restrictions, and follow-up. A multidisciplinary panel of experts from a level I pediatric trauma center was convened to develop and implement a clinical pathway to improve the quality and consistency of care provided to children after MTBI. The clinical pathway, based on current literature and expert consensus, provides a management guideline for the management of MTBI in the emergency department through discharge. The algorithm provides reasonable management options based on the child's clinical presentation, history, and age. Exemplary care of children and their families after MTBI includes appropriate patient/family education. Standardized discharge instructions for MTBI were developed to provide comprehensive information in a succinct and easy-to-read format. The instructions for home management focus on expected symptoms and guidance for when to seek further medical attention. They also incorporate injury prevention, return to sports guidelines, and resources for additional information.