Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children.

BACKGROUND: Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE: Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS: We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS: We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS: There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children.

BACKGROUND: Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation. METHODS: This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity. RESULTS: During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05). CONCLUSIONS: EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

From the street to the ICU: a review of pediatric emergency medical services and critical care transport.

Emergency medical services and critical care transport teams are relatively new parts of the American healthcare delivery system. Although most healthcare providers regularly interact with these groups and rely upon their almost ubiquitous availability, few know how these services developed or what sort of infrastructure currently exists to maintain them. This article provides a focused overview of the history and present practices of both emergency medical services and critical care transport teams, with a concentrated look at the implementation of these services in the pediatric population. Within this context, we also consider current challenges and future opportunities for both groups and conclude with ways to become involved in the improvement of out-of-hospital pediatric critical care.

Setting the Benchmark for the Ground and Air Medical Quality in Transport International Quality Improvement Collaborative.

OBJECTIVE: Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking. METHODS: The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests). RESULTS: Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance. CONCLUSION: Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks.

Intubation Success in Critical Care Transport: A Multicenter Study.

INTRODUCTION: Tracheal intubation (TI) is a lifesaving critical care skill. Failed TI attempts, however, can harm patients. Critical care transport (CCT) teams function as the first point of critical care contact for patients being transported to tertiary medical centers for specialized surgical, medical, and trauma care. The Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement Collaborative uses a quality metric database to track CCT quality metric performance, including TI. We sought to describe TI among GAMUT participants with the hypothesis that CCT would perform better than other prehospital TI reports and similarly to hospital TI success. METHODS: The GAMUT Database is a global, voluntary database for tracking consensus quality metric performance among CCT programs performing neonatal, pediatric, and adult transports. The TI-specific quality metrics are "first attempt TI success" and "definitive airway sans hypoxia/hypotension on first attempt (DASH-1A)." The 2015 GAMUT Database was queried and analysis included patient age, program type, and intubation success rate. Analysis included simple statistics and Pearson chi-square with Bonferroni-adjusted post hoc z tests (significance = p < 0.05 via two-sided testing). RESULTS: Overall, 85,704 patient contacts (neonatal n [%] = 12,664 [14.8%], pediatric n [%] = 28,992 [33.8%], adult n [%] = 44,048 [51.4%]) were included, with 4,036 (4.7%) TI attempts. First attempt TI success was lowest in neonates (59.3%, 617 attempts), better in pediatrics (81.7%, 519 attempts), and best in adults (87%, 2900 attempts), p < 0.001. Adult-focused CCT teams had higher overall first attempt TI success versus pediatric- and neonatal-focused teams (86.9% vs. 63.5%, p < 0.001) and also in pediatric first attempt TI success (86.5% vs. 75.3%, p < 0.001). DASH-1A rates were lower across all patient types (neonatal = 51.9%, pediatric = 74.3%, adult = 79.8%). CONCLUSIONS: CCT TI is not uncommon, and rates of TI and DASH-1A success are higher in adult patients and adult-focused CCT teams. TI success rates are higher in CCT than other prehospital settings, but lower than in-hospital success TI rates. Identifying factors influencing TI success among high performers should influence best practice strategies for TI.

Benchmarking Pain Assessment Rate in Critical Care Transport.

The purpose of this study is to determine the rate of pain assessment in pediatric neonatal critical care transport (PNCCT). The GAMUT database was interrogated for an 18-month period and excluded programs with less than 10% pediatric or neonatal patient contacts and less than 3 months of any metric data reporting during the study period. We hypothesized pain assessment during PNCCT is superior to prehospital pain assessment rates, although inferior to in-hospital rates. Sixty-two programs representing 104,445 patient contacts were analyzed. A total of 21,693 (20.8%) patients were reported to have a documented pain assessment. Subanalysis identified 17 of the 62 programs consistently reporting pain assessments. This group accounted for 24,599 patients and included 7,273 (29.6%) neonatal, 12,655 (51.5%) pediatric, and 4,664 (19.0%) adult patients. Among these programs, the benchmark rate of pain assessment was 90.0%. Our analysis shows a rate below emergency medical services and consistent with published hospital rates of pain assessment. Poor rates of tracking of this metric among participating programs was noted, suggesting an opportunity to investigate the barriers to documentation and reporting of pain assessments in PNCCT and a potential quality improvement initiative.

Quality Metrics in Neonatal and Pediatric Critical Care Transport: A National Delphi Project.

OBJECTIVES: The transport of neonatal and pediatric patients to tertiary care facilities for specialized care demands monitoring the quality of care delivered during transport and its impact on patient outcomes. In 2011, pediatric transport teams in Ohio met to identify quality indicators permitting comparisons among programs. However, no set of national consensus quality metrics exists for benchmarking transport teams. The aim of this project was to achieve national consensus on appropriate neonatal and pediatric transport quality metrics. DESIGN: Modified Delphi technique. SETTING: The first round of consensus determination was via electronic mail survey, followed by rounds of consensus determination in-person at the American Academy of Pediatrics Section on Transport Medicine's 2012 Quality Metrics Summit. SUBJECTS: All attendees of the American Academy of Pediatrics Section on Transport Medicine Quality Metrics Summit, conducted on October 21-23, 2012, in New Orleans, LA, were eligible to participate. MEASUREMENTS AND MAIN RESULTS: Candidate quality metrics were identified through literature review and those metrics currently tracked by participating programs. Participants were asked in a series of rounds to identify "very important" quality metrics for transport. It was determined a priori that consensus on a metric's importance was achieved when at least 70% of respondents were in agreement. This is consistent with other Delphi studies. Eighty-two candidate metrics were considered initially. Ultimately, 12 metrics achieved consensus as "very important" to transport. These include metrics related to airway management, team mobilization time, patient and crew injuries, and adverse patient care events. Definitions were assigned to the 12 metrics to facilitate uniform data tracking among programs. CONCLUSIONS: The authors succeeded in achieving consensus among a diverse group of national transport experts on 12 core neonatal and pediatric transport quality metrics. We propose that transport teams across the country use these metrics to benchmark and guide their quality improvement activities.

Intubation in Pediatric/Neonatal Critical Care Transport: National Performance.

BACKGROUND: There are nearly 200,000 US infants/children transported annually for specialty care and there are no published best practices in transport intubation. OBJECTIVE: Respiratory interventions are a priority in pediatric and neonatal critical care transport (PNCCT). A recent Delphi study identified intubation performance as an important PNCCT quality metric, though data are insufficient. The objective of the study is to determine multi-center rates of first attempt intubation success in pediatric/neonatal transport and identify practice processes associated with higher performing centers. METHODS: Retrospective chart review where data was collected from the 9 participating centers over a 6-month period from January-June 2013. Data describing intubation training and practices were gathered using SurveyMonkey® (Palo Alto, CA). Data were tabulated in Microsoft Excel (Redmond, WA) and analyzed using descriptive statistics. Through the determination of 1(st) intubation success rate across multiple pediatric/neonatal critical care transport programs, we hypothesized that the features of higher and lower performing centers can be identified to inform practice. RESULTS: 9 of 14 invited institutions participated. The median (IQR) 6-month transport volume for neonates(neo) was 289(35-646) and pediatric (ped) 510(122-831). On average, 7%(+/-3.0) of neo and 1.6%(+/-0.7) of ped transport patients required intubation. Individual centers had their initial success rate calculated and a 95% confidence interval was determined for those centers satisfying the np > 5 and n(1-p) > 5 sample size requirement for normality assumption of proportions. Since the overall success rate was 64%, it was determined that n = 14 initial intubation attempts would be the minimum number needed per center in order to fulfill the sample size requirement for normality assumption. Centers whose 95% confidence interval did not contain the initial overall success rate were identified. CONCLUSION: This represents the first multi-center neo/ped intubation dataset in PNCCT. First attempt intubation success lags behind reported anesthesia intubation rates but parallels pediatric emergency department intubation success rates. Training and operational processes are variable in PNCCT, though top performing teams require live-patient intubation success to achieve initial intubation competency.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport.

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.

Specialty pediatric transport in primary care or urgent care settings.

OBJECTIVE: We sought to describe a single center's experience with specialized critical care transport from non-hospital settings, including primary care offices and urgent care centers. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by specialized pediatric critical care transport (SPCCT) teams. METHODS: This study sought to retrospectively evaluate instances where children (0-18 years old) were transported by our SPCCT team from nonhospital settings, including primary care offices and urgent care centers, in 2009 and 2010. Data were extracted from a customized database and appropriate statistical tests were applied, including Fisher's exact test for categorical comparisons and Mann-Whitney U test for non-parametric data comparisons. RESULTS: Fifty-two patients were included. Most of the children were transported for respiratory distress (78%), and many were treated with albuterol (42%) and steroids (42%) prior to the SPCCT team arrival. The most common interventions performed by the SPCCT team were obtaining IV access and administering IV fluid boluses; 4 (7.7%) patients required advanced critical care treatments unique to SPCCT. Most patients (n = 34; 65%) were directly admitted to the general care floor, but a high number of patients (n = 12; 23%; PICU = 11, NICU = 1) required pediatric or neonatal intensive care unit admission. Only 3 patients (5.7%) were discharged home without hospital admission. For the 11 patients admitted to the PICU, the median length of stay (LOS) was 2.5 days (IQR 0.14-13.2). All patients survived to hospital discharge with an additional hospital LOS of 1.3 days (IQR 0.2-6.7). Patients were billed for these critical care transports an average of $2,660.14 ± $940. CONCLUSION: Our small cohort demonstrates infrequent application of advanced critical care interventions beyond those provided by the referring primary care office or urgent care centers. This supports the practice of SPCCT teams providing transport services for select critically ill children at primary care offices and urgent care centers, but not as a standard practice for most pediatric patients in these settings.

Evaluation of regional hospitals' use of children in disaster drills.

OBJECTIVE: Describe the prevalence of pediatric casualties in disaster drills by community hospitals and determine if there is an association between the use of pediatric casualties in disaster drills and the proximity of a community hospital to a tertiary children's hospital. DESIGN: Survey, descriptive study. SETTING: Tertiary children's hospital and surrounding community hospitals. PARTICIPANTS: Hospital emergency management personnel for 30 general community hospitals in the greater Cincinnati, Ohio region. INTERVENTIONS: None MAIN OUTCOME MEASURE(S): The utilization of pediatric casualties in community hospital disaster drills and its relationship to the distance of those hospitals from a tertiary children's hospital. RESULTS: Sixteen hospitals reported a total of 57 disaster drills representing 1,309 casualties. The overwhelming majority (82 percent [1,077/1,309]) of simulated patients from all locations were 16 years of age or older. Those hospitals closest to the children's hospital reported the lowest percentage of pediatric patients (10 percent [35/357]) used in their drills. The hospitals furthest from the children's hospital reported the highest percentage of pediatric patients (32 percent [71/219]) used during disaster drills. CONCLUSIONS: The majority of community hospitals do not incorporate children into their disaster drills, and the closer a community hospital is to a tertiary children's hospital, the less likely it is to include children in its drills. Focused effort and additional resources should be directed toward preparing community hospitals to care for children in the event of a disaster.

Quality metrics in neonatal and pediatric critical care transport: a consensus statement.

OBJECTIVES: The transport of neonatal and pediatric patients to tertiary care medical centers for specialized care demands monitoring the quality of care delivered during transport and its impact on patient outcomes. Accurate assessment of quality indicators and patient outcomes requires the use of a standard language permitting comparisons among transport programs. No consensus exists on a set of quality metrics for benchmarking transport teams. The aim of this project was to achieve consensus on appropriate neonatal and pediatric transport quality metrics. DESIGN: Candidate quality metrics were identified through literature review and those metrics currently tracked by each program. Consensus was governed by nominal group technique. Metrics were categorized in two dimensions: Institute of Medicine quality domains and Donabedian's structure/process/outcome framework. SETTING: Two-day Ohio statewide quality metrics conference. SUBJECTS: Nineteen transport leaders and staff representing six statewide neonatal/pediatric specialty programs convened to achieve consensus. MEASUREMENT AND MAIN RESULTS: Two hundred fifty-seven performance metrics relevant to neonatal/pediatric transport were identified. Eliminating duplicate and overlapping metrics resulted in 70 candidate metrics. Nominal group methodology yielded 23 final quality metrics, the largest portion representing Donabedian's outcome category (n = 12, 52%) and the Institute of Medicine quality domains of effectiveness (n = 7, 30%) and safety (n = 9, 39%). Sample final metrics include measurement of family presence, pain management, intubation success, neonatal temperature control, use of lights and sirens, and medication errors. Lastly, a definition for each metric was established and agreed upon for consistency among institutions. CONCLUSIONS: This project demonstrates that quality metrics can be achieved through consensus building and provides the foundation for benchmarking among neonatal and pediatric transport programs and quality improvement projects.

Pediatric and neonatal interfacility transport: results from a national consensus conference.

The practice of pediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile ICUs capable of delivering state-of-the-art critical care during pediatric and neonatal transport. The most recent document regarding the practice of pediatric/neonatal transport is more than a decade old. The following article details changes in the practice of interfacility transport over the past decade and expresses the consensus views of leaders in the field of transport medicine, including the American Academy of Pediatrics' Section on Transport Medicine.

The impact of postintubation chest radiograph during pediatric and neonatal critical care transport.

OBJECTIVES: Tracheal intubation is necessary in the setting of pediatric/neonatal critical care transport but information regarding usefulness and efficiency of a confirmatory postintubation chest radiograph is limited. We hypothesize that routine postintubation chest radiograph to confirm tracheal tube position is not informative and can be eliminated to improve efficiency without compromising safety in transport. DESIGN: This was a prospective observational study. The primary study outcome was the rate of tracheal tube repositioning after postintubation chest radiograph and the secondary outcome was the on-scene time. Additional data obtained included the initial accuracy of tracheal tube depth based on Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines. SETTING: A children's hospital-based pediatric/neonatal critical care transport team in northeastern Ohio. PATIENTS: All pediatric/neonatal patients intubated by the transport team during the 18-month study period (January 2009-July 2010). MEASUREMENTS AND MAIN RESULTS: There were 77 patients enrolled (43 pediatric, 34 neonatal). A postintubation chest radiograph was obtained 85.7% of the time and showed tracheal tube malposition in 47% of cases. No difference was seen in the rate of malpositioned tracheal tubes in the neonatal group compared with pediatric group (51.7% vs. 43.2%, p = 0.54). The calculated tracheal tube depth based on the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines was correct in 50% of the neonates and 41.9% of the pediatric patients. In patients with appropriate initial tracheal tube depth by calculations, the tracheal tube was repositioned at similar rates after postintubation chest radiograph in both neonatal and pediatric patients (50% vs. 41.9%, p = 0.48). When comparing mean onscene times for patients with/without a postintubation chest radiograph, the neonatal patients saved 33 minutes on average when no chest radiograph was obtained (mean ± sd: 60.6 ± 35.8 min vs. 93.8 ± 23.8 min, p = 0.01). There was no statistical difference in on-scene time for pediatric patients whether they did or did not receive a postintubation chest radiograph. CONCLUSIONS: Although postintubation chest radiographs may extend the overall on-scene transport times in select patients, our data show that the postintubation chest radiographs remain informative in pediatric/neonatal critical care specialty transport and should be obtained when feasible.

Making good better: implementing a standardized handoff in pediatric transport.

BACKGROUND: Failures in communication lead to adverse events in healthcare. Handoffs, defined as the transfer of information, responsibility, and authority from one provider to another, have been identified as a cause of communication failure compromising patient safety. Locally, there was dissatisfaction among caregivers working on the general care and intensive care units regarding the quality of information received from the pediatric transport team for transferred patients. METHODS: Using the Model for Improvement, a quality improvement team was engaged to lead this improvement effort. The team developed a standardized and scripted transport handoff process that incorporated parental input. The primary measure was provider satisfaction (reported as overall handoff score, OHS). Secondary outcomes included the use of components outlined by the Joint Commission's guidelines for safe handoff. Data were collected using a Likert-style survey and collated using Microsoft Excel. RESULTS: Baseline measures of OHS were 81.5 ± 19.4 (mean±SD) with an interval analysis showing no improvement (81.6±17.4, P=0.99). Further modifications were made to both education and process with an improved OHS (88.8±11.1, P<0.05). Certain specific handoff components showed the greatest improvement according to caregivers. CONCLUSION: This practical, low-cost quality-improvement project may help others improve handoff communication and provide safe, high-quality care.

Heliox in children with croup: a strategy to hasten improvement.

OBJECTIVE: Upper airway obstruction is responsive to the reduction in airflow turbulence provided by helium/oxygen (heliox) admixture. Our pediatric critical care transport team (PCCTT) has used heliox for children with upper airway obstruction from croup. We sought to describe our experience with heliox on transport and hypothesized that heliox-treated children with croup would show a more rapid clinical improvement. METHODS: Children with croup transported by our PCCTT and admitted to the PICU were evaluated. We analyzed pretransport care, transport interventions, and outcomes. Croup scores (Modified Taussig) were assigned retrospectively according to respiratory therapy charting. Data were analyzed using appropriate statistical tests, including Pearson's chi-square test, Fisher's exact test, Mann-Whitney U rank comparison, and two-sample t-test. RESULTS: Thirty-five children met inclusion criteria. Demographics were similar between groups. The pretransport medical care was similar between groups. Children receiving heliox had a higher baseline croup score [mean (SD) = 5.7(2.3) vs no heliox 2.9 (2.0), P < 0.001]. The improvement in croup scores over the first 60 minutes of transport was more rapid in the heliox-treated children (P < 0.001). There was no difference in the number of children requiring additional nebulized racemic epinephrine during transport. The PICU length of stay (P = 0.59) and hospital length of stay (P = 0.64) were similar between groups. CONCLUSION: Heliox added to standard transport treatment for critically ill children with croup provides a more rapid improvement in croup scores. Heliox for croup during transport does not prolong intensive care unit stay. A prospective clinical trial is warranted to evaluate heliox in pediatric transport.

Missed opportunities during pediatric residency training: report of a 10-year follow-up survey in critical care transport medicine.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires pediatric residency training programs to provide exposure to the prehospital management and transport of patients. The authors hypothesized that compared with a similar study a decade prior, current pediatric residency training programs have reduced requirements for participation in transport medicine, thus reducing further the opportunities for residents to learn the management of critically ill infants and children. METHODS: In 2009, a questionnaire was distributed to 182 pediatric residency program directors. The authors obtained information regarding the neonatal and pediatric transport teams, the training program size, and the pediatric residents' role in the transport team. RESULTS: Sixty-eight (37%) of the 182 surveyed institutions responded. Residents were involved in neonatal and pediatric transports in 42.8% and 55.0% of programs, respectively. When involved in transports, residents were the neonatal and pediatric team leaders 44.4% and 42.4% of the time, respectively. Evaluation of resident transport performance occurred consistently in only 23.3% (neonatal) and 21% (pediatric) of programs. Most programs (90.3%) endorsed the concept of a curriculum that would uniquely provide an integrated experience in critical care transport to increase resident exposure, competence, and confidence. CONCLUSIONS: Pediatric residency participation in neonatal and pediatric critical care transport continued to decline among training programs. Residents participating in transports were less likely to function as team leaders and frequently did not receive performance evaluations. Most respondents welcomed a curriculum that would increase residents' exposure to the critically ill infants and children transported by neonatal and pediatric teams.

Hyperbilirubinemia: current guidelines and emerging therapies.

It is estimated that about two thirds of newborns will appear clinically jaundiced during their first weeks of life. As newborns and their mothers spend fewer days in the hospital after birth, the number of infants readmitted yearly in the United States for neonatal jaundice over the last 10 years has increased by 160%. A portion of these infants present to the emergency department, requiring a careful history and physical examination assessing them for the risk factors associated with pathologic bilirubin levels. Although the spectrum of illness may be great, the overwhelming etiology of neonatal jaundice presenting to an emergency department is physiologic and not due to infection or isoimmunization. Therefore, a little more than a good history, physical examination, and indirect/direct bilirubin levels are needed to evaluate an otherwise well-appearing jaundiced newborn. The American Academy of Pediatrics' 2004 clinical practice guidelines for "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation" are a helpful and easily accessible resource when evaluating jaundiced newborns (available at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297). There are several exciting developments on the horizon for the diagnosis and management of hyperbilirubinemia including increasing use of transcutaneous bilirubin measuring devices and medications such as tin mesoporphyrin and intravenous immunoglobulin that may decrease the need for exchange transfusions.

Pediatric emergency medicine residency experience: requirements versus reality.

BACKGROUND: An important expectation of pediatric education is assessing, resuscitating, and stabilizing ill or injured children. OBJECTIVE: To determine whether the Accreditation Council for Graduate Medical Education (ACGME) minimum time requirement for emergency and acute illness experience is adequate to achieve the educational objectives set forth for categorical pediatric residents. We hypothesized that despite residents working five 1-month block rotations in a high-volume (95 000 pediatric visits per year) pediatric emergency department (ED), the comprehensive experience outlined by the ACGME would not be satisfied through clinical exposure. STUDY DESIGN: This was a retrospective, descriptive study comparing actual resident experience to the standard defined by the ACGME. The emergency medicine experience of 35 categorical pediatric residents was tracked including number of patients evaluated during training and patient discharge diagnoses. The achievability of the ACGME requirement was determined by reporting the percentage of pediatric residents that cared for at least 1 patient from each of the ACGME-required disorder categories. RESULTS: A total of 11.4% of residents met the ACGME requirement for emergency and acute illness experience in the ED. The median number of patients evaluated by residents during training in the ED was 941. Disorder categories evaluated least frequently included shock, sepsis, diabetic ketoacidosis, coma/altered mental status, cardiopulmonary arrest, burns, and bowel obstruction. CONCLUSION: Pediatric residents working in one of the busiest pediatric EDs in the country and working 1 month more than the ACGME-recommended minimum did not achieve the ACGME requirement for emergency and acute illness experience through direct patient care.