Newborn Screening Pulse Oximetry to Detect Critical Congenital Heart Disease: A Follow-Up Survey of Current Practice at Army, Navy and Air Force Hospitals.

INTRODUCTION: The purpose of this study was to assess the evolution of newborn pulse oximetry screening (+POx) among Army, Air Force, and Naval military hospitals (MH), including prevalence, protocol use, quality assurance processes, access to echocardiography, and use of telemedicine. This is a follow-up from a prior study published in 2011. MATERIALS AND METHODS: An Internet-based questionnaire was forwarded to the chief pediatrician at MH worldwide which support newborn deliveries. Descriptive data were reported using percentages. Grouped responses, as applicable, were further compared using the chi-square test. A p-value < 0.05 was considered statistically significant. RESULTS: Seventy-eight percent (36/46) of MH supporting deliveries worldwide responded to the survey (17 Army hospitals, 11 Navy Hospitals, 8 Air Force hospitals). All responding hospitals utilize +POx, of which 94% endorsed protocol compliance with the American Academy of Pediatrics guidelines. Nine (25%) hospitals were located outside of the United States. Delivery volumes (infants per month) range between 1-49 (36%), 50-99 (28%), 100-199 (19%), and 200-300 (17%). Eleven hospitals reported regular review of +POx data, with most reviewing them monthly. Four MH share findings with state institutions. Ten hospitals either have a staff pediatric cardiologist or use tele-echocardiography for on-site evaluations. Ten hospitals are located greater than 60 miles from the nearest center with echocardiography capabilities. Of the five hospitals using tele-echocardiography, four confirmed critical congenital heart disease (CCHD) using this practice, and all five reported averting transfer of an infant using this technology. Of the 22 hospitals lacking the ability to obtain on-site echocardiography, 12 (55%) are interested in implementing a tele-echocardiography protocol. CONCLUSIONS: All responding MH use +POx, representing significant increase from the 30% of MH reporting use of +POx seven years ago. The majority of MH follow AAP +POx guidelines, and though most have providers review results prior to discharge, only one-third report periodic chart review for quality assurance. Most MH transfer infants with positive +POx results for evaluation due to a lack of on-site echocardiography. Tele-echocardiography was reported as a potential solution to diagnose or rule out CCHD. Over half of remaining hospitals without cardiologists are interested in using this technology to evaluate stable infants with positive CCHD screening.

Discordance between resident and faculty perceptions of resident autonomy: can self-determination theory help interpret differences and guide strategies for bridging the divide?

PURPOSE: To identify and interpret differences between resident and faculty perceptions of resident autonomy and of faculty support of resident autonomy. METHOD: Parallel questionnaires were sent to pediatric residents and faculty at the University of Rochester Medical Center in 2011. Items addressed self-determination theory (SDT) constructs (autonomy, competence, relatedness) and asked residents and faculty to rate and/or comment on their own and the other group's behaviors. Distributions of responses to 17 parallel Likert scale items were compared by Wilcoxon rank-sum tests. Written comments underwent qualitative content analysis. RESULTS: Respondents included 62/78 residents (79%) and 71/100 faculty (71%). The groups differed significantly on 15 of 17 parallel items but agreed that faculty sometimes provided too much direction. Written comments suggested that SDT constructs were closely interrelated in residency training. Residents expressed frustration that their care plans were changed without explanation. Faculty reported reluctance to give "passive" residents autonomy in patient care unless stakes were low. Many reported granting more independence to residents who displayed motivation and competence. Some described working to overcome residents' passivity by clarifying and reinforcing expectations. CONCLUSIONS: Faculty and residents had discordant perceptions of resident autonomy and of faculty support for resident autonomy. When faculty restrict the independence of "passive" residents whose competence they question, residents may receive fewer opportunities for active learning. Strategies that support autonomy, such as scaffolding, may help residents gain confidence and competence, enhance residents' relatedness to team members and supervisors, and help programs adapt to accreditation requirements to foster residents' growth in independence.

Quality improvement educational practices in pediatric residency programs: survey of pediatric program directors.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residents to learn quality improvement (QI) methods to analyze, change, and improve their practice. Little is known about how pediatric residency programs design, implement, and evaluate QI curricula to achieve this goal. We sought to describe current QI educational practices, evaluation methods, and program director perceptions through a national survey. METHODS: A survey of QI curricula was developed, pilot tested, approved by the Association of Pediatric Program Directors (APPD), and distributed to pediatric program directors. Descriptive statistics were used to analyze the data. RESULTS: The response rate was 53% (104 of 197). Most respondents reported presence of a QI curriculum (85%, 88 of 104), including didactic sessions (83%) and resident QI projects (88%). Continuous process improvement was the most common methodology addressed (65%). The most frequent topics taught were "Making a Case for QI" (68%), "PDSA [plan-do-study-act] Cycles" (66%), and "Measurement in QI" (60%). Projects were most frequently designed to improve clinical care (90%), hospital operations (65%), and the residency (61%). Only 35% evaluated patient outcomes, and 17% had no formal evaluation. Programs had a mean of 6 faculty members (standard deviation 4.4, range 2-20) involved in teaching residents QI. Programs with more faculty involved were more likely to have had a resident submit an abstract to a professional meeting about their QI project (<5 faculty, 38%; 5-9, 64%; >9, 92%; P = .003). Barriers to teaching QI included time (66%), funding constraints (39%), and absent local QI expertise (33%). Most PPDs (65%) believed that resident input in hospital QI was important, but only 24% reported resident involvement. Critical factors for success included an experiential component (56%) and faculty with QI expertise (50%). CONCLUSIONS: QI curricular practices vary greatly across pediatric residency programs. Although pediatric residency programs commit a fair number of resources to QI education and believe that resident involvement in QI is important, fundamental QI topics are overlooked in many programs, and evaluation of existing curricula is limited. Success as perceived by pediatric program directors appears to be related to the inclusion of a QI project and the availability of faculty mentors.

Pediatric resident education in quality improvement (QI): a national survey.

OBJECTIVE: To assess pediatric residents' perceptions of their quality improvement (QI) education and training, including factors that facilitate learning QI and self-efficacy in QI activities. METHODS: A 22-question survey questionnaire was developed with expert-identified key topics and iterative pretesting of questions. Third-year pediatric residents from 45 residency programs recruited from a random sample of 120 programs. Data were analyzed by descriptive statistics, chi-square tests, and qualitative content analysis. RESULTS: Respondents included 331 residents for a response rate of 47%. Demographic characteristics resembled the national profile of pediatric residents. Over 70% of residents reported that their QI training was well organized and met their needs. Three quarters felt ready to use QI methods in practice. Those with QI training before residency were significantly more confident than those without prior QI training. However, fewer than half of respondents used standard QI methods such as PDSA cycles and run charts in projects. Residents identified faculty support, a structured curriculum, hands-on projects, and dedicated project time as key strengths of their QI educational experiences. A strong QI culture was also considered important, and was reported to be present in most programs sampled. CONCLUSIONS: Overall, third-year pediatric residents reported positive QI educational experiences with strong faculty support and sufficient time for QI projects. However, a third of residents thought that the QI curricula in their programs needed improvement, and a quarter lacked self-efficacy in conducting future QI activities. Continuing curricular improvement, including faculty development, is warranted.