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1.
Pediatr Qual Saf ; 7(1): e510, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35071953

RESUMO

INTRODUCTION: Coronavirus Disease-2019 presents risk to both patients and medical teams. Staff-intensive, complex procedures such as extracorporeal membrane oxygenation (ECMO) or extracorporeal cardiopulmonary resuscitation (eCPR) may increase chances of exposure and spread. This investigation aimed to rapidly deploy an in situ Simulation-based Clinical Systems Testing (SbCST) framework to identify Latent Safety Threats (LSTs) related to ECMO/eCPR initiation during a pandemic. METHODS: The adapted SbCST framework tested systems related to ECMO/eCPR initiation in the Neonatal and Pediatric Intensive Care Units. Systems were evaluated in six domains (Resources, Processes/Systems, Facilities, Clinical Performance, Infection Control, and Communication). We conducted three high-fidelity simulations with members from the Neonatal Intensive Care Unit General Surgery, Pediatric Intensive Care Unit Cardiovascular Surgery (CV), and Pediatric Intensive Care Unit General Surgery teams. Content experts evaluated systems issues during simulation, and LSTs were identified during debriefing. Data were analyzed for frequency of LSTs and trends in process gaps. RESULTS: Sixty-six LSTs were identified across three scenarios. Resource issues comprised the largest category (26%), followed by Process/System issues (24%), Infection Control issues (24%), Communication issues (17%), and Facility and Clinical Performance issues (5% each). LSTs informed new team strategies such as the use of a "door/PPE monitor" and "inside/outside" team configuration. CONCLUSIONS: The adapted SbCST framework identified multiple LSTs related to ECMO/eCPR cannulation and infection control guidelines in the setting of Coronavirus Disease-2019. Through SbCSTs, we developed guidelines to conserve PPE and develop optimal workflows to reduce patient/staff exposure in a high-risk procedure. This project may guide other hospitals to adapt SbCSTs strategies to test/adjust rapidly changing guidelines.

2.
Pediatrics ; 139(3)2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28174202

RESUMO

When minors are asked to assist medical educators by acting as standardized patients (SPs), there is a potential for the minors to be exploited. Minors deserve protection from exploitation. Such protection has been written into regulations governing medical research and into child labor laws. But there are no similar guidelines for minors' work in medical education. This article addresses the question of whether there should be rules. Should minors be required to give their informed consent or assent? Are there certain practices that could cause harm for the children who become SPs? We present a controversial case and ask a number of experts to consider the ethical issues that arise when minors are asked to act as SPs in medical education.


Assuntos
Educação de Graduação em Medicina/ética , Menores de Idade , Simulação de Paciente , Adolescente , Criança , Humanos , Consentimento Livre e Esclarecido , Consentimento dos Pais
3.
Acad Emerg Med ; 23(1): 48-54, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26720488

RESUMO

OBJECTIVES: Changes in health care delivery and graduate medical education have important consequences for the workforce in pediatric emergency medicine (PEM). This study compared career preparation and potential attrition of the PEM workforce with the prior assessment from 1998. METHODS: An e-mail survey was sent to members of the American Academy of Pediatrics (AAP) Section on EM and to non-AAP members board certified in PEM. Information on demographics, practice characteristics and professional activities, career preparation, future plans, and burnout (using two validated screening questions) was analyzed using standard descriptive statistics. RESULTS: Of 2,120 surveys mailed, 895 responses were received (40.8% response). Over half (53.7%) of respondents were female, compared with 44% in 1998. The majority (62.9%) practiced in the emergency department (ED) of a free-standing children's hospital. The distribution of professional activities was similar to that reported in 1998, with the majority of time (60%) spent in direct patient care. Half indicated involvement in research, and almost half had dedicated time for other activities, including emergency medical services (7.3%), disaster (6.9%), child abuse (5.0%), transport (3.6%), toxicology (2.3% of respondents), and other (13.6%); additionally, 21.3% had dedicated time for quality/safety. Respondents were highly satisfied (95.6%) with fellowship preparation for clinical care, but less satisfied with preparation for research (49.2%) and administration (38.7%). However, satisfaction with nonclinical training was higher for those within 10 years of medical school graduation. Forty-six percent plan to change clinical activity in the next 5 years, including reducing hours, changing shifts, or retiring. Overall, 11.9% of all respondents, including 20.1% of women and 2.6% of men (p < 0.001), report currently working part time. Large majorities endorsed feeling burned out at work (88.5%) or more callous toward people as a result of work (67.5%) at least monthly, with one in five reporting such feelings at least weekly. CONCLUSIONS: While satisfaction with fellowship preparation for professional activities in PEM is improving, gaps remain in training in nonclinical skills. Symptoms of burnout are prevalent, and there is likely to be substantial attrition of PEM providers in the near future.


Assuntos
Esgotamento Profissional/epidemiologia , Serviços Médicos de Emergência , Medicina de Emergência , Bolsas de Estudo/organização & administração , Unidades de Terapia Intensiva Pediátrica , Pediatria/educação , Adulto , Esgotamento Profissional/prevenção & controle , Criança , Educação de Pós-Graduação em Medicina , Serviços Médicos de Emergência/organização & administração , Medicina de Emergência/educação , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica/normas , Masculino , Pediatria/organização & administração , Recursos Humanos
8.
Am J Pharm Educ ; 74(7): 120, 2010 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-21088725

RESUMO

OBJECTIVE: To design and implement a demonstration project to teach interprofessional teams how to recognize and engage in difficult conversations with patients. DESIGN: Interdisciplinary teams consisting of pharmacy students and residents, student nurses, and medical residents responded to preliminary questions regarding difficult conversations, listened to a brief discussion on difficult conversations; formed ad hoc teams and interacted with a standardized patient (mother) and a human simulator (child), discussing the infant's health issues, intimate partner violence, and suicidal thinking; and underwent debriefing. ASSESSMENT: Participants evaluated the learning methods positively and a majority demonstrated knowledge gains. The project team also learned lessons that will help better design future programs, including an emphasis on simulations over lecture and the importance of debriefing on student learning. Drawbacks included the major time commitment for design and implementation, sustainability, and the lack of resources to replicate the program for all students. CONCLUSION: Simulation is an effective technique to teach interprofessional teams how to engage in difficult conversations with patients.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Bacharelado em Enfermagem/métodos , Educação em Farmácia/métodos , Comunicação em Saúde , Manequins , Equipe de Assistência ao Paciente , Aprendizagem Baseada em Problemas/métodos , Adulto , Humanos , Lactente , Bem-Estar do Lactente/psicologia , Comunicação Interdisciplinar , Missouri , Mães/educação , Mães/psicologia , Projetos Piloto , Maus-Tratos Conjugais/psicologia , Estresse Psicológico , Estudantes de Ciências da Saúde/psicologia , Ideação Suicida , Inquéritos e Questionários
9.
Pediatrics ; 122(4): 726-30, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18829794

RESUMO

OBJECTIVE: The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis. METHODS: We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture. RESULTS: We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with >or=12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL). CONCLUSIONS: In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.


Assuntos
Antibacterianos/uso terapêutico , Bactérias/isolamento & purificação , Líquido Cefalorraquidiano/microbiologia , Meningites Bacterianas/líquido cefalorraquidiano , Adolescente , Biomarcadores/metabolismo , Líquido Cefalorraquidiano/citologia , Líquido Cefalorraquidiano/metabolismo , Criança , Pré-Escolar , Seguimentos , Glucose/líquido cefalorraquidiano , Humanos , Lactente , Recém-Nascido , Contagem de Leucócitos , Leucocitose/líquido cefalorraquidiano , Leucocitose/etiologia , Meningites Bacterianas/complicações , Meningites Bacterianas/tratamento farmacológico , Proteínas/metabolismo , Estudos Retrospectivos , Índice de Gravidade de Doença , Punção Espinal , Estados Unidos
10.
JAMA ; 297(1): 52-60, 2007 Jan 03.
Artigo em Inglês | MEDLINE | ID: mdl-17200475

RESUMO

CONTEXT: Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation. OBJECTIVE: To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination. DESIGN, SETTING, AND PATIENTS: A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture. MAIN OUTCOME MEASURE: The sensitivity and negative predictive value of the Bacterial Meningitis Score. RESULTS: Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized. CONCLUSIONS: This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.


Assuntos
Técnicas de Apoio para a Decisão , Leucocitose/líquido cefalorraquidiano , Meningites Bacterianas/diagnóstico , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Meningite Asséptica/epidemiologia , Meningites Bacterianas/epidemiologia , Vacinas Pneumocócicas , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade
11.
Pediatr Emerg Care ; 22(11): 728-31, 2006 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17110866

RESUMO

The purpose of this case report is to illustrate the diagnostic difficulties of congestive heart failure in an infant. When presenting to the emergency department, these patients are often evaluated for sepsis, congenital heart disease, metabolic disorders, and myocarditis. We report a case of a 3(1/2)-month-old male who presented to the pediatric emergency department with congestive heart failure. He was found to have vitamin D deficiency rickets induced cardiomyopathy.


Assuntos
Aleitamento Materno/efeitos adversos , Insuficiência Cardíaca/etiologia , Transtornos Respiratórios/etiologia , Raquitismo/diagnóstico , Cálcio/uso terapêutico , Cardiomegalia/etiologia , Diagnóstico Diferencial , Eletrocardiografia , Emergências , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/diagnóstico por imagem , Ruídos Cardíacos , Humanos , Lactente , Cuidado do Lactente , Masculino , Insuficiência da Valva Mitral/etiologia , Oligúria/etiologia , Transtornos Respiratórios/tratamento farmacológico , Raquitismo/complicações , Raquitismo/tratamento farmacológico , Ultrassonografia , Disfunção Ventricular Esquerda/etiologia , Vitamina D/uso terapêutico
13.
Pediatr Emerg Care ; 21(8): 502-6, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16096594

RESUMO

OBJECTIVES: This study was performed at an urban children's hospital to identify the characteristics of patients given human immunodeficiency virus (HIV) postexposure prophylaxis and describe the adherence and associated side effects of HIV prophylaxis in child and adolescent victims of sexual abuse. METHODS: A retrospective review of all children presenting for evaluation of suspected sexual abuse who were provided HIV prophylaxis between February 1999 and March 2001 was performed. Measured variables included risk factors for transmission of HIV, antiretrovirals prescribed and their side effects, initial and follow-up laboratory results, and compliance. RESULTS: The medical records of 34 patients were examined. Assault by a stranger was the most common risk factor prompting prophylaxis. Zidovudine and lamivudine were prescribed for 32 patients (94%). Only 17 patients (50%) kept at least 1 follow-up appointment; 8 patients (24%) finished the entire course of prophylaxis. Side effects were reported in 11 (65%) of 17 patients, but only 1 patient was known to have stopped prophylaxis because of subjective side effects, and 1 patient was removed from prophylaxis due to laboratory abnormality. CONCLUSIONS: Adherence to medication regimen and follow-up appointments in victims of suspected sexual abuse who are provided HIV prophylaxis is poor. The medications are associated with several side effects, but rarely do the side effects prohibit their use. Given difficulties with compliance, potential adverse effects of medications, and the high cost of treatment, care should be taken in offering prophylaxis to only those at increased risk for transmission of disease.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Abuso Sexual na Infância , Infecções por HIV/prevenção & controle , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , HIV , Hospitais Urbanos , Humanos , Lactente , Masculino , Meio-Oeste dos Estados Unidos , Estudos Retrospectivos , Infecções Sexualmente Transmissíveis/prevenção & controle
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