A National Perspective on the Current Educational Environment in Pediatric Community-Based Continuity Clinic.

OBJECTIVE: To characterize current practices of US pediatric residency programs around use of community-based continuity clinics for residency training. METHODS: A national, anonymous survey was sent electronically to all US pediatric program directors (PDs) through the Association of Pediatric Program Directors (APPD). The survey assessed preceptor recruitment, faculty development, teaching methods, and PDs' satisfaction with the experience and teaching at community sites. Data were analyzed using descriptive statistics and Chi2 Test of Independence. RESULTS: A total of 99 of 200 (50%) programs responded. Fifty-six percent (55/99) did not sent any residents into the community. Of the remaining 44 programs, 48% had difficulty recruiting preceptors. Only 34% require preceptors to engage in faculty development around teaching and less than half require community preceptors to work through a formal curriculum. Almost all PDs that sent residents to community-based practices were very to extremely satisfied with resident experiences (84%), but 37% were not satisfied with residents having their own patient panel. CONCLUSIONS: While the majority of PD's were satisfied with resident experiences in community-based sites, recruitment was challenging, and teaching and faculty development methods varied. Determining incentives to help recruitment, ensuring use of a formal primary care curriculum and providing faculty development around teaching, will be critical for training.

Pediatric Chief Resident Exchange Program-A Novel Method to Share Educational Ideas Across Training Programs.

BACKGROUND: Pediatric residency programs offer many conferences and activities to meet the educational needs of their residents. We developed and assessed the Pediatric Chief Resident Exchange Program where pediatric chief residents visited another institution for a day with the goal of sharing educational and curricular innovations between residency programs in an experiential manner. APPROACH/INNOVATION: Pediatric chief residents participated in various activities during the exchange including educational conferences and discussions with residency program leadership at the host institutions. Surveys were administered to all participating chiefs to determine if any changes to educational conferences or curriculum were made or planned to be made at their home program based upon what they observed at the other institution and to have chiefs reflect on what they gained from the experience. RESULTS: Twenty-eight chief residents from 9 programs participated in the exchange program over 3 academic years (2015-2018). All respondents felt the exchange experience was worthwhile. The majority (67%) of programs planned to implement a change at their institution based on participation in the exchange with over half actually making a change by the end of the academic year. Participating chiefs gained a sense of camaraderie, appreciated that other programs experienced similar struggles, and developed further insight into the chief resident role. DISCUSSION: The Pediatric Chief Resident Exchange Program is a novel method of sharing educational practices between institutions that can lead to curricular changes at participating programs. It can also be an opportunity for chief resident professional development.

Traumatic Pulmonary Herniation at the Diaphragmatic Junction in a Pediatric Patient: A Rare Complication of Blunt Chest Trauma.

We present a case of traumatic intercostal pulmonary herniation in an 11-year-old boy after blunt trauma to the chest, without associated chest wall disruption or pneumothorax. This condition is especially uncommon in children, with only 5 previously reported cases and most occurring after penetrating chest trauma. To date, there are no reports in literature describing traumatic intercostal lung herniation at the diaphragmatic junction with a closed chest cavity in a child. The number of traumatic lung herniation diagnoses may be expanded by a more liberal use of computed tomography when serious injury is suspected. Computed tomography and advanced imaging should be considered in pediatric trauma patients presenting with concern for intrathoracic injury that may not be seen on plain film. Traumatic blunt intrathoracic and intra-abdominal injuries in the pediatric population that are within proximity of diaphragmatic insertion should be thoroughly evaluated to rule out diaphragmatic injury. As in our case, invasive surgical intervention such as thoracoscopy may be necessary.

Insurance status and the variable management of children presenting to the emergency department with bronchiolitis.

OBJECTIVE: To determine if insurance type is associated with differences in the management of children presenting to the emergency department (ED) with bronchiolitis METHODS: We analyzed data from a 30-center, prospective cohort study of children younger than 2 years with bronchiolitis presenting to the ED. Insurance status was defined as private, public, and no insurance. RESULTS: Of 1450 patients, 473 (33%) had private, 928 (64%) had public, and 49 (3%) had no insurance. Multivariable analysis found that children with public insurance were less likely to receive inhaled ß-agonists (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.92) or antibiotics (OR, 0.61; 95% CI, 0.42-0.89) the week before the ED visit. Children without insurance were less likely to have a primary care provider (OR, 0.15; 95% CI, 0.04-0.57) or receive laboratory testing in the ED (OR, 0.41; 95% CI, 0.19-0.88). The children's clinical presentation (eg, respiratory rate, oxygen saturation, and retractions) and ED treatments (eg, inhaled ß-agonists, inhaled racemic epinephrine, systemic corticosteroids, and antibiotics) were similar. Likewise, hospital admission (multivariable OR 1.04; 95% CI, 0.45-2.42) was similar between insurance groups. CONCLUSIONS: We noted some pre-ED and ED management differences across insurance types for children presenting to the ED with bronchiolitis. Although these variations may reflect treatments with unproven benefits, all children regardless of insurance should receive similar care. Despite these management variations, there were no differences in medications delivered in the ED or admission rate.

Evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students.

OBJECTIVES: To examine the effectiveness of an asynchronous learning tool consisting of web-based lectures for trainees covering major topics pertinent to pediatric emergency medicine (PEM) and to assess resident and student evaluation of this mode of education. METHODS: PEM faculty and fellows created a 21-lecture, web-based curriculum. These 20-minute online lectures used Microsoft PowerPoint with the voice-over feature. A 75-question test was created to assess the effectiveness of the web-based learning model, administered online before and after the rotation in the pediatric emergency department (PED). All fourth-year medical students and residents (across all specialties) rotating through the PED were required to complete 10 of the 21 lectures during their 1-month rotation. The main outcome variable was difference in score between pre- and post-rotation tests of participants who viewed no lectures and those who viewed at least one lecture. Evaluation of the program was assessed by anonymous survey using 5-point discrete visual analog scales. Responses of 4 or 5 were considered positive for analysis. RESULTS: One hundred eleven residents and fourth-year medical students participated in the program. An initial 32 completed testing before implementation of the on-line lectures (March 2007-August 2007), and another five did not complete the on-line lectures after implementation (September 2007-February 2008). Seventy-one completed testing and on-line lectures, and all but three completed at least 10 on-line lectures during their rotation. Fourteen of 111 trainees did not complete the pre- or post-test (including two who viewed the lectures). The mean change in score was a 1% improvement from pre-test to post-test for trainees who viewed no lectures and a 6.2% improvement for those who viewed the lectures (mean difference = 5.2%, 95% confidence interval = 2.5% to 7.9%). In the linear regression model, the estimate of the coefficient was 0.43 (p < 0.001), meaning that, for each lecture viewed, post-test score rose by 0.43%. Sixty-nine of 75 test items (92%) had a point biserial correlation greater than 0.15. Thirty of the 72 trainees who completed the online lectures and testing (42%) returned surveys. All were comfortable using the Internet, and 87% (26/30) found the web-site easy to use. All felt that their educational goals were met, and 100% felt that the format would be useful in other areas of education. CONCLUSIONS: Although not a replacement for traditional bedside teaching, the use of web-based lectures as an asynchronous learning tool has a positive effect on medical knowledge test scores. Trainees were able to view online lectures on their own schedules, in the location of their choice. This is helpful in a field with shift work, in which trainees rarely work together, making it difficult to synchronously provide lectures to all trainees.

Handedness effects on procedural training in pediatrics.

OBJECTIVE: To determine handedness effects on procedural training. PATIENTS AND METHODS: Pediatric trainees and attendings from 3 institutions participated in a Web-based survey examining whether handedness affected learning procedures, the hand used to perform procedures, and if handedness training was received. RESULTS AND CONCLUSIONS: Of 778 physicians, 39% completed surveys, and 11% wrote with their left hand. Learning procedures were affected in left-handed physicians (60% vs 7.7%; odds ratio [OR] = 17.9; 95% confidence interval [CI] = 7.9-40.1), and they used their non-dominant or both hands to perform procedures (48.6% vs 21%; OR = 3.6; 95% CI = 1.7-7.4). Few physicians received handedness training (20% vs 10.7%; P= .16). Left-handed physicians were affected learning lumbar puncture (29% vs 4%; OR= 10.0; 95% CI = 3.8-26.4), intubation (36% vs 5%; OR=11.0; 95% CI=4.4-27.4), and suturing (32% vs 4%; OR = 11.7; 95% CI = 4.5-30.5).

Prospective multicenter bronchiolitis study: predicting intensive care unit admissions.

OBJECTIVES: The authors sought to identify predictors of intensive care unit (ICU) admission among children hospitalized with bronchiolitis for > or =24 hours. METHODS: The authors conducted a prospective cohort study during two consecutive bronchiolitis seasons, 2004 through 2006, in 30 U.S. emergency departments (EDs). All included patients were aged <2 years and had a final diagnosis of bronchiolitis. Regular floor versus ICU admissions were compared. RESULTS: Of 1,456 enrolled patients, 533 (37%) were admitted to the regular floor and 50 (3%) to the ICU. Comparing floor and ICU admissions, multivariate ED predictors of ICU admission were age <2 months (26% vs. 53%; odds ratio [OR] = 4.1; 95% confidence interval [CI] = 2.1 to 8.3), an ED visit the past week (25% vs. 40%; OR = 2.2; 95% CI = 1.1 to 4.4), moderate/severe retractions (31% vs. 48%; OR = 2.6; 95% CI = 1.3 to 5.2), and inadequate oral intake (31% vs. 53%; OR = 3.3; 95% CI = 1.6 to 7.1). Unlike previous studies, no association with male gender, socioeconomic factors, insurance status, breast-feeding, or parental asthma was found with ICU admission. CONCLUSIONS: In this prospective multicenter ED-based study of children admitted for bronchiolitis, four independent predictors of ICU admission were identified. The authors did not confirm many putative risk factors, but cannot rule out modest associations.

Ethyl vinyl chloride vapocoolant spray fails to decrease pain associated with intravenous cannulation in children.

The purpose of the study was to determine the effect of ethyl vinyl chloride vapocoolant spray on pain reported by children undergoing intravenous cannulation. A randomized, double-blinded, placebo-controlled trial was conducted on eligible children between the ages of 9 and 18 years seen in a pediatric emergency department and requiring intravenous cannulation. Informed consent was obtained, and children were randomized to receive ethyl vinyl chloride spray, isopropyl alcohol spray, or no spray (control group). Patient demographics and information pertaining to each intravenous cannulation were recorded. Children indicated the degree of pain associated with intravenous cannulation on a 100-mm visual analog scale (VAS) compared to a baseline pain score of "zero." Statistical analysis was performed by using Stata version 7. One hundred twenty-seven subjects were enrolled: 37 received ethyl vinyl chloride vapocoolant spray, 48 received isopropyl alcohol spray (placebo), and 42 received no pretreatment. Mean VAS scores for pain experienced during cannulation were 34, 33, and 31 mL for each group, respectively. Ethyl vinyl chloride vapocoolant spray failed to measurably reduce pain associated with intravenous cannulation when compared to those pretreated with isopropyl alcohol spray or receiving no intervention.

Effect of a standardized pharyngitis treatment protocol on use of antibiotics in a pediatric emergency department.

BACKGROUND: Pharyngitis is a common complaint in pediatric patients. If clinical parameters are used alone, bacterial pathogens will be wrongly implicated in many cases. A nonstandardized approach to the treatment of children with pharyngitis in an emergency department setting may lead to inappropriate empirical therapy, contribute to increased bacterial resistance, and result in adverse events related to the treatment provided. OBJECTIVE: To implement evidence-based guidelines for the diagnosis and treatment of children with pharyngitis in an emergency department setting and thereby influence practices of prescribing antibiotics. DESIGN AND METHODS: An evidence-based guideline for the evaluation and treatment of patients with pharyngitis was developed and implemented in our emergency department. Preintervention and postintervention patient cohorts were identified by a search of the emergency department's clinical repository. A medical record review was performed using a standardized data abstraction form (history and examination data, diagnostic testing, and therapy provided). Treatment decisions were judged as appropriate if the diagnosis of pharyngitis caused by group A beta-hemolytic streptococci was based on confirmatory microbiological testing rather than on the history and physical examination findings alone. RESULTS: We included 443 patients for study (219 preintervention and 224 postintervention). In the preintervention group, 97 (44%) of 214 received appropriate treatment. In the postintervention group, 204 (91%) of 224 received appropriate treatment. CONCLUSION: An evidence-based clinical guideline can influence and improve practices of prescribing antibiotics by pediatric emergency physicians in a teaching hospital setting.

The educational experience of pediatric emergency medicine fellows in the use and application of procedural sedation/analgesia.

OBJECTIVES: The purpose of this study is to describe the clinical and educational experience provided to the pediatric emergency medicine (PEM) fellows in procedural sedation/analgesia during their course of training. METHODS: A nonanonymous survey was completed by the program director of each Accreditation Council for Graduate Medical Education (ACGME)-accredited PEM fellowship program listed in the 2001 to 2002 Graduate Medical Education Directory. Information relating to program demographics, agents available for use in the emergency department (ED), and the educational opportunities offered to trainees was sought. RESULTS: Each of the 32 ACGME-accredited programs completed the survey. Thirty programs report using procedural sedation and analgesia (PSA) to facilitate the completion of nonpainful and 32 programs to facilitate the completion of painful procedures in the ED. Twenty-nine programs (92%) permit their fellows to provide PSA independently after meeting credentialing criteria at their institution. Formal didactic sessions, direct supervision of procedures, and dedicated journal clubs were the 3 most frequently cited educational methods reported. The educational method chosen was not predicted by the ED type, the size of the training program, or by the volume of patients evaluated in the ED. Twelve program directors report their belief that a minimum number of procedures should be completed prior to completion of the training program. CONCLUSION: There is wide variation in the educational methods used by PEM fellowship training programs in procedural sedation/analgesia.

Patterns in childhood sports injury.

OBJECTIVE: The purpose of this epidemiologic study is twofold: first, to determine the relative frequency of sports-related injuries compared with all musculoskeletal injuries in patients 5 to 21 years of age presenting to the emergency department (ED), and second, to evaluate the sports-specific and anatomic site-specific nature of these injuries. METHODS: Patterns of injury in patients 5 to 21 years of age presenting to four pediatric EDs with musculoskeletal injuries in October 1999 and April 2000 were prospectively studied. Information collected included age, sex, injury type, anatomical injury site, and cause of injury (sports-related or otherwise). Information about patient outcome and disposition was also obtained. RESULTS: There were a total of 1421 injuries in 1275 patients. Musculoskeletal injuries were more common in male patients (790/62%) than in female patients. The mean age of the patients was 12.2 years (95% CI, 12.0-12.4). Sprains, contusions, and fractures were the most common injury types (34, 30, and 25%, respectively). Female patients experienced a greater percentage of sprains (44% vs 36%) and contusions (37% vs 33%) and fewer fractures (22% vs 31%) than male patients. Sports injuries accounted for 41% (521) of all musculoskeletal injuries and were responsible for 8% (495/6173) of all ED visits. Head, forearm, and wrist injuries were most commonly seen in biking, hand injuries in football and basketball, knee injuries in soccer, and ankle and foot injuries in basketball. CONCLUSIONS: Sports injuries in children and adolescents were by far the most common cause of musculoskeletal injuries treated in the ED, accounting for 41% of all musculoskeletal injuries. This represents the highest percentage of sports-related musculoskeletal injuries per ED visit reported in children to date. As children and adolescents participate in sports in record numbers nationwide, sports injury research and prevention will become increasingly more important.

Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter.

CONTEXT: Blood culture is the criterion standard for identifying children with bacteremia. However, elevated false-positive rates are common and are associated with substantial health care costs. OBJECTIVE: To compare contamination rates in blood culture specimens obtained from separate sites vs through newly inserted intravenous catheters. DESIGN, SETTING, AND PARTICIPANTS: Observational study conducted January 1998 through December 1999 among patients aged 18 years or younger who were seen at a US children's hospital emergency department and had a blood culture obtained as part of their care. Medical records were reviewed in all cases with a positive blood culture. Patients with indwelling vascular catheters were excluded. INTERVENTION: All phlebotomy was performed by emergency department registered nurses. During the baseline phase, blood specimens for culture were obtained simultaneously with intravenous catheter insertion. During the postintervention phase, specimens were obtained by a separate, dedicated procedure. MAIN OUTCOME MEASURE: Contamination rate in the postintervention period compared with the baseline period. RESULTS: A total of 4108 blood cultures were evaluated, including 2108 during the baseline phase and 2000 in the postintervention phase. The false-positive blood culture rate decreased from 9.1% to 2.8% (P<.001). A statistical process control chart demonstrated a steady-state process in the baseline phase and the establishment of a significantly improved steady state in the postintervention phase. Young age was associated with increased contamination rate in both the baseline and postintervention periods. CONCLUSION: Blood culture contamination rates were lower when specimens were drawn from a separate site compared with when they were drawn through a newly inserted intravenous catheter.