Primary Palliative Care for Pediatric Residents: A Curricular Framework and Pilot.

PROBLEM: Palliative care (PC) is high-value, holistic care for a child and their family across the entire arc of an illness. All physicians should be competent in symptom management and providing goal-concordant care that acknowledges the quality of life; however, there is insufficient education in pediatric residency to develop competence in basic or ..úPrimary..Ñ PC. APPROACH: We completed a needs assessment and developed a longitudinal, comprehensive, and integrated primary PC curriculum for pediatric residents with the goal of developing foundational primary PC skills regardless of eventual career trajectory. After 1 year of implementation, we assessed resident comfort with primary PC skills via a retrospective pre-post survey. OUTCOMES: We found a statistically significant (P.ß<.ß.05) increase in residents... comfort with pain management, delivering serious news, and discussing goals of care. An increase in comfort with the management of other symptoms was not statistically significant. NEXT STEPS: After 1 year of implementation, residents describe an increase in comfort with primary PC skills. The next steps include more rigorous evaluation and expansion to include more education in medical ethics. While the educational need is universal, resident needs are constantly evolving and each institution should tailor this curriculum to fit their specific trainee needs and institutional expertise.

Implementing Resident Team Assistant Programs at Academic Medical Centers: Lessons Learned.

BACKGROUND: Excessive inpatient administrative tasks can lead to adverse consequences for residents and their patients. Furthermore, this burden has been linked to depersonalization, a major component of physician burnout. OBJECTIVE: To describe the development, implementation, feasibility, acceptability, and early outcomes of Resident Team Assistant (RTA) programs. METHODS: Three large academic medical centers created RTA programs in which administrative assistants are incorporated into inpatient medical teams. First steps included a needs assessment and driver diagram creation to identify key issues and to solidify goals. Program directors were assigned, and RTAs were hired, trained, and incorporated into inpatient teams at each institution (2003, 2016, 2018). Program leadership and institutional stakeholders met regularly to discuss development and quality assurance. Surveys and direct interviews were performed to evaluate impact and acceptability. Institutional goals in accordance to RTAs tasks were also investigated. RESULTS: Resident surveys and interviews have shown acceptability with RTAs completing a large percentage of resident administrative tasks while promoting time spent in direct clinical care and job satisfaction. Hospital-specific improvements have included increase in referring physician communication rate and decrease in work hour violations. The programs have maintained high feasibility and sustainability with a relatively low time commitment from leadership and cost for the institutions. CONCLUSIONS: The RTA programs at the 3 institutions have continued to be sustained over time with perceived improvements in administrative task burden and job satisfaction for the residents. They have maintained high acceptability and feasibility in terms of effort and costs for the hospitals.

A Pediatric Preintern Boot Camp: Program Development and Evaluation Informed by a Conceptual Framework.

OBJECTIVE: Boot camps are being developed and implemented by a growing number of medical schools to facilitate medical students' transition to internship. However, there is limited conceptual understanding of how this facilitation occurs. METHODS: We developed and piloted a 1-week pediatric boot camp in 2015, then significantly revised and evaluated the program in 2016-2017 using a conceptual framework of self-efficacy. Consistent with this framework, the revised boot camp focuses on enhancing practical skills that can ease medical students' transition to internship. Observations and course evaluations informed process evaluation, whereas learner assessments immediately after and at 6 months after the boot camp informed outcomes evaluation in terms of both perceived self-efficacy and confidence. RESULTS: Medical students valued sessions that were "hands on," and program improvements were made to include a variety of interactive curricular activities. Data from course evaluations provided evidence of increased perceived self-efficacy. Learner assessment showed a medium to large effect size for confidence in nearly all specific skills that were queried and a positive, albeit attenuated, effect on perceived self-efficacy at 6 months. CONCLUSIONS: Program evaluation of a pediatric boot camp informed by a conceptual framework of self-efficacy shed light on how it might facilitate medical students' transition to internship. A similar conceptual framework may be useful for other trainee preparatory courses.

Efficacy of a Web-Based Oral Case Presentation Instruction Module: Multicenter Randomized Controlled Trial.

OBJECTIVE: Effective self-directed educational tools are invaluable. Our objective was to determine whether a self-directed, web-based oral case presentation module would improve medical students' oral case presentations compared to usual curriculum, and with similar efficacy as structured oral presentation faculty feedback sessions. METHODS: We conducted a pragmatic multicenter cluster randomized controlled trial among medical students rotating in pediatric clerkships at 7 US medical schools. In the clerkship's first 14 days, subjects were instructed to complete an online Computer-Assisted Learning in Pediatrics Program (CLIPP) oral case presentation module, an in-person faculty-led case presentation feedback session, or neither (control). At the clerkship's end, evaluators blinded to intervention status rated the quality of students' oral case presentations on a 10-point scale. We conducted intention-to-treat multivariable analyses clustered on clerkship block. RESULTS: Study participants included 256 CLIPP (32.5%), 263 feedback (33.3%), and 270 control (34.2%) subjects. Only 51.1% of CLIPP subjects completed the assigned presentation module, while 98.5% of feedback subjects participated in presentation feedback sessions. Compared to controls, oral presentation quality was significantly higher in the feedback group (adjusted difference in mean quality, 0.28; 95% confidence interval, 0.08, 0.49) and trended toward being significantly higher in the CLIPP group (0.19; 95% confidence interval, -0.006, 0.38). The quality of presentations in the CLIPP and feedback groups was not significantly different (-0.10; 95% confidence interval, -0.31, 0.11). CONCLUSIONS: The quality of oral case presentations delivered by students randomized to complete the CLIPP module did not differ from faculty-led presentation feedback sessions and was not statistically superior to control.

Orbital, Mediastinal and Cervicofacial Subcutaneous Emphysema after Dental Rehabilitation in a Pediatric Patient.

Subcutaneous emphysema is a rare possible complication of dental procedures. The majority of the dental literature describes cases of localized areas of subcutaneous emphysema following various dental procedures, with a large number of these cases seen following intraoral surgical procedures. Classically, subcutaneous emphysema occurs within minutes to hours after conclusion of dental procedures and is commonly misdiagnosed as either an allergic reaction or acute post-operative swelling. This case report describes a four-year-old male who underwent dental rehabilitation for routine restorative dentistry without extractions under general anesthesia. He subsequently developed extensive subcutaneous emphysema involving the right periorbital region, cervicofacial spaces, and caudal extension to include the superior aspect of the mediastinum. The purpose of this report was to provide a brief review of the prior literature on the subject, report on the case, and review the management for patients with subcutaneous emphysema.

Determining preventability of pediatric readmissions using fault tree analysis.

BACKGROUND: Previous studies attempting to distinguish preventable from nonpreventable readmissions reported challenges in completing reviews efficiently and consistently. OBJECTIVES: (1) Examine the efficiency and reliability of a Web-based fault tree tool designed to guide physicians through chart reviews to a determination about preventability. (2) Investigate root causes of general pediatrics readmissions and identify the percent that are preventable. DESIGN/SETTING/PATIENTS: General pediatricians from The Children's Hospital of Philadelphia used a Web-based fault tree tool to classify root causes of all general pediatrics 15-day readmissions in 2014. INTERVENTION/MEASUREMENTS: The tool guided reviewers through a logical progression of questions, which resulted in 1 of 18 root causes of readmission, 8 of which were considered potentially preventable. Twenty percent of cases were cross-checked to measure inter-rater reliability. RESULTS: Of the 7252 discharges, 248 were readmitted, for an all-cause general pediatrics 15-day readmission rate of 3.4%. Of those readmissions, 15 (6.0%) were deemed potentially preventable, corresponding to 0.2% of total discharges. The most common cause of potentially preventable readmissions was premature discharge. For the 50 cross-checked cases, both reviews resulted in the same root cause for 44 (86%) of files (κ = 0.79; 95% confidence interval: 0.60-0.98). Completing 1 review using the tool took approximately 20 minutes. CONCLUSION: The Web-based fault tree tool helped physicians to identify root causes of hospital readmissions and classify them as either preventable or not preventable in an efficient and consistent way. It also confirmed that only a small percentage of general pediatrics 15-day readmissions are potentially preventable. Journal of Hospital Medicine 2016;11:329-335. © 2016 Society of Hospital Medicine.

Description and Evaluation of an Educational Intervention on Health Care Costs and Value.

OBJECTIVE: There is growing consensus that to ensure that health care dollars are spent efficiently, physicians need more training in how to provide high-value, cost-conscious care. Thus, in fiscal year 2014, The Children's Hospital of Philadelphia piloted a 9-part curriculum on health care costs and value for faculty in the Division of General Pediatrics. This study uses baseline and postintervention surveys to gauge knowledge, perceptions, and views on these issues and to assess the efficacy of the pilot curriculum. METHODS: Faculty completed surveys about their knowledge and perceptions about health care costs and value and their views on the role physicians should play in containing costs and promoting value. Baseline and postintervention responses were compared and analyzed on the basis of how many of the sessions respondents attended. RESULTS: Sixty-two faculty members completed the baseline survey (71% response rate), and 45 faculty members completed the postintervention survey (63% response rate). Reported knowledge of health care costs and value increased significantly in the postintervention survey (P=.04 and P<.001). Odds of being knowledgeable about costs and value were 2.42 (confidence interval: 1.05-5.58) and 6.22 times greater (confidence interval: 2.29-16.90), respectively, postintervention. Reported knowledge of health care costs and value increased with number of sessions attended (P=.01 and P<.001). CONCLUSIONS: The pilot curriculum appeared to successfully introduce physicians to concepts around health care costs and value and initiated important discussions about the role physicians can play in containing costs and promoting value. Additional education, increased cost transparency, and more decision support tools are needed to help physicians translate knowledge into practice.