Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions.

OBJECTIVES: Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. METHODS: We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. RESULTS: A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. CONCLUSIONS: Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.

Attitudes and Beliefs of Pediatric Residents and Physician Assistant Students Toward Screening Adolescents for Suicide in Primary Care.

INTRODUCTION: The objectives of this study were to: (1) describe attitudes of health professional trainees for conducting routine screening for suicidal ideation with adolescents; (2) identify the relationship between intention to conduct suicide risk assessments and behavioral attitudes, norm referents, and behavioral control; and (3) investigate the relationship between intention to conduct these assessments and self-reported clinic behavior. METHODS: Second-year physician assistant (PA) students and pediatric residents (MD) at 3 universities voluntarily completed an anonymous cross-sectional questionnaire. The questionnaire was guided by the Theory of Planned Behavior and included items about previous experience with suicide. Pearson correlation and multivariable linear regression were used to analyze the data. RESULTS: There were usable and complete data for 105 respondents (n = 105). The sample included PA students (89.52%, n = 94) and pediatric residents (10.48%, n = 11). Trainees were significantly more likely to have higher intention to conduct suicide risk assessments when they reported greater behavioral control (Std. ß = 0.34, p <0.001) and reported suicide being discussed during previous clinic visits as a student/resident (Std. ß = 0.21, p = 0.03), controlling for profession, race, behavioral attitudes, and norm referents. Trainees were significantly more likely to report conducting suicide risk assessments when they had greater behavioral control (Std. ß = 0.27, p = 0.01) and greater intention to conduct these assessments (Std. ß = 0.21, p = 0.03), controlling for profession, race, behavioral attitudes, and norm referents. DISCUSSION: Second-year PA students and pediatric residents support screening adolescents for suicide risk. Training on methods to increase behavioral control may increase rates of screenings.

Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management.

Simulation training is central in preparing practitioners for code management that is free from patient harm.1 The purpose of this study was to determine if using a high-fidelity simulator in pediatric code education would improve trainee confidence and competency compared with the use of a traditional mannequin in the same setting. METHODS: Fifty-third-year medical students participated in Pediatric Advanced Life Support code training, including a mock code scenario. Students were randomized into two groups and assigned to a simulator group: high-fidelity simulator (Group 1) or traditional mannequin (Group 2). To assess competency, trainees were evaluated using a checklist of required verbalized items or performed during the mock code scenario. To assess confidence, trainees completed pre- and postintervention confidence surveys, which were collected and compared. RESULTS: Both Group 1 and Group 2 reported increased overall confidence in code management upon completion of their training. Although confidence increased universally, Group 1 reported increased confidence over that of Group 2 in three specific areas: ability to treat respiratory arrest, ability to run a code, and knowledge of the Pediatric Advanced Life Support algorithm. Group 1 also demonstrated increased competency in code management compared with Group 2 in four key code components: checking airway, checking breathing, checking pulses, and checking capillary refill. CONCLUSIONS: Trainee confidence increases after completion of Pediatric Advanced Life Support code training, regardless of simulator type utilized. However, trainees were more competent in code management when trained using a high-fidelity simulator compared with a traditional mannequin.

Addition of CORES to the I-PASS Handoff: A Resident-led Quality Improvement Study.

Quality patient handoff is vital in patient care and attainable with structured handoff systems, such as the I-PASS mnemonic. This paper describes a continuous quality improvement study occurring after the implementation of the I-PASS handoff bundle. Our objectives were to (1) determine compliance with the inclusion of I-PASS elements during handoff and (2) determine whether the addition of CORES, an electronic tool that generates a patient list designed for use with I-PASS, would improve compliance and sustainability. METHODS: We developed an aim statement: 90% of handoffs would include all 6 I-PASS elements within 6 months of the addition of CORES. Two plan-do-study-act (PDSA) cycles were conducted. In PDSA 1, we implemented CORES. In PDSA 2, we reeducated residents on I-PASS elements and the importance of a quality handoff. We used a checklist to evaluate the inclusion of I-PASS elements. Following PDSA 2, we administered a survey regarding CORES to involved residents. RESULTS: During PDSA 1, illness severity, diagnosis, patient summary, contingency planning, action list, and receiver synthesis were present in 13%, 62%, 52%, 87%, 42%, and 25% of handoffs, respectively. Overall compliance was 47%. During PDSA 2, illness severity remained stable at 13% whereas the remainder increased to 84%, 82%, 93%, 91%, and 37%. Overall compliance increased to 67%. Following PDSA 2, 100% of survey respondents reported improved handoff with CORES. CONCLUSIONS: In this study, we show that neither implementation of CORES nor resident reeducation resulted in the return to high postintervention compliance observed after implementation of the I-PASS handoff bundle.

Using Resident and Faculty Focus Groups to Obtain Stakeholder Input during the ACGME Self-study.

INTRODUCTION: The Accreditation Council for Graduate Medical Education describes steps to guide programs regarding self-study. The process relies heavily on obtaining stakeholder input to validate findings. Focus groups have been noted to provide input and data not elicited using other methods. Our objective was to show the value of focus groups in obtaining a clear picture of stakeholder priorities as they relate to program aims, opportunities, threats, areas for improvement, and sustainability of improvements. METHODS: We conducted a series of focus groups in 2017-2018 at a pediatric residency program with residents and core faculty members. The first session for each group elicited input regarding program aims, opportunities, and threats. The second session focused on evaluating program progress over the past 10 years and identifying strengths and needed areas for improvement. We documented responses obtained during the focus groups and used inductive content analysis methods to identify major themes. We repeated the focus groups every 6 months. RESULTS: We identified 8 program aims and pinpointed opportunities and threats. Areas for improvement were selected and then presented back to the stakeholders who confirmed their appropriateness. Repetition of the focus groups every 6 months facilitated ongoing measurement of progress and promoted the development of multiple plan, do, study, act cycles for areas of improvement. CONCLUSIONS: Focus groups are an effective way to initiate the self-study process, examine the program aims, opportunities, and threats, and formulate a detailed improvement plan. They are also useful as part of continual evaluation during a dynamic change process.

Developing and Validating a Step Test of Aerobic Fitness among Elementary School Children.

Purpose: The tests to estimate aerobic fitness among children require substantial space and maximum effort, which is often difficult for children. We developed a simple submaximal step test (Step Test of Endurance for Pediatrics, or STEP) and assessed its reliability, validity, and ability to estimate aerobic fitness among elementary school children. Method: Children aged 5-10 years completed the STEP with a protocol consisting of 0.1-, 0.2-, and 0.3-metre (4, 8, and 12 in.) step heights. Participants underwent treadmill testing with open circuit spirometry to determine actual maximal oxygen consumption (V̇o2max). Intra-class correlation coefficients (ICCs) assessed test-retest reliability of the STEP and its component tests. Multivariate linear regression assessed the associations between the STEP and V̇o2max, adjusting for potential covariates such as age, sex, BMI, and comorbidity count. Results: The STEP showed excellent reliability (ICC ≥ 0.92; N = 170), irrespective of effort level during testing. Significant effort issues and collinearity among the independent variables led us to exclude children aged 5-6 years (n = 45) from the regression analysis. The final regression model for children aged 7-10 years with adequate effort (n = 111), as defined by a respiratory exchange ratio of 1.0 or more, showed that the STEP, sex, and BMI were significantly predictive of V̇o2max (R 2 = 0.51). Conclusions: This new, effort-independent step test can estimate the aerobic fitness of children aged 7-10 years. Regression equations to estimate V̇o2max from the STEP were provided.

Objectif : les tests d'évaluation de la capacité aérobique chez les enfants exigent beaucoup d'espace et un effort maximal, et les enfants éprouvent souvent de la difficulté à les exécuter. La présente étude visait à mettre à l'essai un simple test sous-maximal de la marche d'escalier (test de la marche d'escalier pour établir l'endurance en pédiatrie, ou STEP, selon l'acronyme anglais) et à en déterminer la fiabilité, la validité et la capacité à évaluer la capacité aérobique des enfants du primaire. Méthodologie : des enfants de cinq à dix ans ont effectué le STEP selon un protocole qui incluait des marches de 0,1, 0,2 et 0,3 mètre (4, 8 et 12 pouces). Les participants ont effectué une épreuve d'effort sur tapis roulant avec spirométrie en circuit ouvert pour déterminer leur consommation maximale réelle d'oxygène (V̇o2max). Les chercheurs ont utilisé les coefficients de corrélation intraclasse (CCI) pour évaluer la fiabilité test-retest du STEP et des tests qui le composaient. Ils ont utilisé la régression linéaire multivariée pour évaluer les associations entre le STEP et le V̇o2max, rajustée pour tenir compte de covariances potentielles comme l'âge, le sexe, l'indice de masse corporelle (IMC) et le nombre de comorbidités. Résultats : le STEP était d'une excellente fiabilité (CCI ≥ 0,92; n = 170), quel que soit le niveau d'effort utilisé. Des problèmes relatifs à l'importance de l'effort et la colinéarité entre les variables indépendantes ont incité les chercheurs à exclure de l'analyse de régression les enfants de cinq et six ans (n = 45). Le modèle de régression final des enfants de sept à dix ans qui faisaient un effort approprié (n = 111), défini par un ratio d'échanges gazeux minimal de 1,0, a révélé que le STEP, le genre et l'IMC étaient très prédictifs du V̇o2max (R 2 = 0,51). Conclusion : ce nouveau test de la marche d'escalier qui n'est pas lié à l'effort peut évaluer la capacité aérobique des enfants de sept à dix ans. Les chercheurs ont fourni les équations de régression pour évaluer le V̇o2max à partir du STEP.

Evaluating the use of high-fidelity simulators during mock neonatal resuscitation scenarios in trying to improve confidence in residents.

OBJECTIVE: The purpose of this study was to investigate the effect of the use of high-fidelity simulators with multidisciplinary teaching on self-reported confidence in residents. METHODS: A total of 26 residents participated in a session led by a pediatric faculty member and a Neonatal Intensive Care Unit transport nurse using a high-fidelity pediatric simulator. Multiple scenarios were presented and each resident took turns in various roles. Pre-intervention surveys based on a 5-point Likert-type scale were given before the scenarios and were compared to the results of identical post-intervention surveys. RESULTS: Statistically significant (p < 0.05) pre to post gains for self-confidence were observed. Improvements in confidence were analyzed using the mean difference. The largest improvement in confidence was seen in the ability to treat neonatal respiratory arrest. This was followed by the ability to supervise/run a code, and the ability to place an umbilical venous catheter. CONCLUSION: These results revealed that high-fidelity simulation-based training has significant positive gains in residents' self-reported confidence.

Idiopathic intracranial hypertension as a presenting sign of adrenal insufficiency.

Idiopathic intracranial hypertension is a diagnosis of exclusion defined by elevated intracranial pressure without mass lesions or hydrocephalus. Causes of idiopathic intracranial hypertension include obesity, vitamin derangements, antibiotics, corticosteroids, and autoimmune disorders. Cushing's disease and Addison's disease have been associated with idiopathic intracranial hypertension. Secondary adrenal insufficiency following withdrawal of inhaled corticosteroids has been found to be a relatively common phenomenon. This case describes an 11-year-old boy who was previously on inhaled corticosteroids for severe asthma who presented with secondary adrenal insufficiency after withdrawal of steroids. The adrenal insufficiency presented as idiopathic intracranial hypertension. We described the hospital course and process of diagnosis for this child with secondary adrenal insufficiency following withdrawal of inhaled corticosteroids. The association between the discontinuation of this patient's corticosteroids and his onset of headache suggests secondary adrenal insufficiency as the most likely cause of his idiopathic intracranial hypertension. The gradual improvement in his symptoms after steroid replacement further supports this. Due to the significant prevalence of children using inhaled corticosteroids, it is important for clinicians to be aware of the potential for the withdrawal of these drugs to induce hypothalamic-pituitary-adrenal axis suppression.

Quality improvement regarding handoff.

BACKGROUND AND OBJECTIVES: Previous studies have emphasized the importance of effectual communication during patient handoffs. The objectives of this study were to (1) implement a resident-driven quality improvement project to improve handoffs by including key elements that are necessary for a safe and effective handoff. We chose to use the IPASS (illness severity, patient summary, action items, situation awareness and contingency planning, synthesis by receiver) mnemonic as our standardized handoff model; (2) Consider balancing measures in an effort to be aware of any negative effects of our interventions on resident satisfaction with the system. METHODS: A senior resident established a quality improvement team which developed an AIM statement (a written, measurable, and time-sensitive description of the goal of a quality improvement team) and key drivers. A survey was administered to residents regarding their opinions about the handoff process. Tracking of whether or not handoffs included the component IPASS elements was performed over an 11-month period. During this time frame, three Plan-Do-Study-Act cycles were conducted. The first was an educational series involving lecture and role playing. The second was printed cards listing appropriate handoff elements. Intervention three was development of a tool and method to decrease nurse interruptions during handoff. RESULTS: Inclusion of six key elements of handoffs improved as follows. Illness severity improved from 5% to 97%, diagnosis from 60% to 100%, patient summary from 71% to 100%, contingency planning from 10% to 100%, action list from 23% to 100%, and receiver synthesis from 0% to 97%. Balancing measures showed the residents were more satisfied with the new system and found it to be more effective at providing a safe transition of care. CONCLUSION: Implementation of a resident-driven multidisciplinary IPASS handoff system resulted in improved inclusion of key handoff elements and increased resident satisfaction.

Improving Resident Knowledge of Spacers.

Studies show the delivery of inhaled medications is maximized when a metered-dose inhaler (MDI) with a spacer is utilized. Our residents expressed concern with their knowledge of MDIs and spacers. This study was designed to address those concerns. Residents were given a 12-question pre-intervention, self-assessment questionnaire that explored their overall knowledge and comfort in utilizing MDI with spacers. Participants then received educational intervention via multimedia videos and a demonstration of proper use of MDI with spacer. Participants were given the same questionnaire immediately following the education and again 3 months later. Improvement was significant (P < .05) for each element studied as derived from the 12 questions. Improvement remained significant when these variables were assessed in the 3-month follow-up. In this study, we successfully improved the ability of our residents to deliver quality care by improving their knowledge and confidence in utilizing MDIs with spacers.

Baylisascaris Procyonis Exposure Case Study.

We report a case of exposure to raccoon feces found to be contaminated with baylisascaris procyonis. The exposure was recognized early enough by the family to allow prophylaxis with albendazole. Because of the potential fatal or neurologically catastrophic effects of this disease immediate treatment is indicated. This is started in advance of environmental studies that are done to determine if the feces is indeed contaminated.

A Quality Improvement Project to Improve Family Recognition of Medical Team Member Roles.

OBJECTIVE: Previous studies have shown that inpatients and families in academic settings have a limited ability to recall either their medical team members or the roles of those members. This is an important issue for patient and family satisfaction as well as patient safety. The objective of this study was to increase families' recognition of medical team members' roles. METHODS: We established a multidisciplinary quality improvement leadership team, measured family recognition of medical team members and their roles, and conducted 2 PDSA (Plan-Do-Study-Act) cycles. The first intervention was standardization of the content and delivery of our verbal team introductions to ensure inclusion of essential elements and family engagement. The second intervention was addition of an informational white board in each patient room. The prospective study included 105 families in the preintervention phase, 103 post-PDSA cycle 1, and 92 post-PDSA cycle 2. RESULTS: After conduction of 2 PDSA cycles, the recognition of the attending role increased from 49% to 87% (P = .000), the resident role from 39% to 73% (P = .000), and the medical student from 75% to 89% (P = .038). CONCLUSIONS: The multidisciplinary quality improvement model was effective in improving family recognition of the roles of attending physicians, resident physicians, and medical students. Consistent attention to engaging the families and explaining our roles as well as providing informational white boards are effective interventions to facilitate this process.

Effects of a Brief Physical Activity Program on Young Students' Physical Fitness.

BACKGROUND: Our objective was to test whether brief daily activity could increase young students' physical fitness and compare different forms of intervention delivery. METHODS: Two intervention groups were instructed to increase children's activity by 6 minutes daily. The principal was responsible for the intervention in the first group while classroom teachers were responsible in the second. The third group was a control. Success was defined by changes in student fitness. RESULTS: The principal-led group had a significant increase in the number of 75-foot laps completed after intervention (+0.61 laps) and a significant decrease in after-exercise heart rate (-37.4 beats per minute) as compared with the control group. The teacher-led group experienced no change in either outcome. CONCLUSIONS: Our findings demonstrate that a 6-minute increase in activity can produce a significant improvement in student fitness. Administrative support of school-based interventions can have a positive impact on program completion.