Implementation and Maturity of Clinical Learning Environment Components Across Pediatric Residency Programs.

OBJECTIVE: Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally. METHODS: We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium. RESULTS: Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than nonrequired components. CONCLUSIONS: To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies.

A Prospective Evaluation of Arrhythmias in a Large Tertiary Neonatal Intensive Care Unit.

Arrhythmias in the neonatal period are common and can be classified as bradyarhythmias and tachyarrhythmias and as benign or non-benign. Neonatal arrhythmias are further differentiated between those with abnormalities in generation (non-sinus) and those with abnormalities in propagation. Because the neonatal myocardium is immature and operates at the peak of the Starling curve, significant changes in heart rate can result in a decline in cardiac output and compromise end-organ perfusion. This is especially true for premature neonates, those critically ill, or those with concomitant congenital heart disease. While sustained arrhythmias are frequently witnessed and recorded in tertiary neonatal intensive care units (NICU) very little data exist on the observance of non-sustained brady- or tachyarrhythmias in this cohort. No prospective study has been performed on all neonates admitted to a large tertiary NICU throughout their entire stay. The purpose of this study was to prospectively evaluate the prevalence and type of arrhythmias in a large NICU population from admission to discharge. All neonates admitted to the NICU at Inova Children's Hospital at Inova Fairfax Medical Campus between January 1, 2021 and April 1, 2021 were prospectively evaluated from admission to hospital discharge via continuous bedside monitoring reviewed every 24 h. Concerning telemetry strips were reviewed by two team members as well as the senior electrophysiologist. Two-hundred and one neonates (mean gestational age = 344/7 weeks) were enrolled in the study. Admission length ranged from 1 to 195 days (total of 5624 patient days, median 16 days). Overall, 68% (N = 137) of admissions had one or more arrhythmias, the most common of which was sinus tachycardia (65%, N = 130), followed by sinus bradycardia (30%, N = 60). Clinically relevant arrhythmias were diagnosed in 6.5% of neonates. During the study period there were four deaths, none of which were directly attributable to a primary arrhythmia. Approximately 68% of neonates exhibited at least one arrhythmia. Although the vast majority of these arrhythmias were benign, clinically relevant arrhythmias were observed in 6.5%. Patients admitted to the NICU appear to have a relatively high burden of benign arrhythmias, but a relatively low burden of pathologic arrhythmias.

Using QI Methodology to Improve a Program's QI Curriculum: An Educational Improvement Project.

Quality improvement (QI) as a method of obtaining meaningful change is increasingly valued. A few comprehensive, longitudinal curricula demonstrate efficacy, patient impact, and behavior change over time. This educational improvement study aimed to create a curriculum that increased resident proficiency in practicing QI principles, score on the QI Knowledge Application Tool-Revised, and QI projects completing at least 2 plan-do-study-act (PDSA) cycles in 5 years. Methods: We utilized The Model for Improvement and sequential PDSA cycles, testing curricular components for improvement. Measures were analyzed annually (2014-2020). The curriculum includes modules and didactic workshops for foundational knowledge, rapid personal improvement projects for putting knowledge into practice, and experiential learning through developing and leading QI projects. Results: Graduating residents reporting proficiency in practicing QI principles increased from 4 (44%) to 11 (100%). The average QI Knowledge Application Tool-Revised score increased from 50% to 94% (95% CI, 37-51). Resident QI projects completing at least 2 PDSA cycles increased from 30% (n = 3) to 100% (n = 4), P = 0.0005, while projects achieving improvement increased from 40% (n = 4) to 100% (n = 3), P = 0.002. Patients were also positively impacted, with 63% (n = 3) of clinical QI projects that measured patient-centered outcomes achieving improvement and 69% (n = 11) of clinical QI projects improving clinical processes. Conclusions: This study developed a curriculum that successfully prepares residents to practice QI principles and lead multidisciplinary QI projects while demonstrating patient impact and behavior change. It offers an example of curriculum development and evaluation aided by QI science.

Not just to survive but to thrive: delirium in the pediatric cardiac ICU.

PURPOSE OF REVIEW: Pediatric delirium has recently been recognized to occur frequently in the pediatric general and cardiac ICU. The purpose of this review is to highlight recent data on the prevalence, prevention, and management of this condition. RECENT FINDINGS: Pediatric delirium occurs in the pediatric cardiac ICU (PCICU) in as many as 67% of patients. Validated screening tools are now available to assist clinicians in the diagnosis of this condition. Research has shown a growing relationship between benzodiazepines, mainstays in the realm of sedation, and delirium. The full spectrum of risk factors has yet to be clearly elucidated. After normalization of the ICU environment, antipsychotics are infrequently required for treatment. While pediatric delirium has been associated with increased length of stay and cost, long-term morbidities are unknown at this time. SUMMARY: Application of bundles to normalize the PCICU environment may lead to decreased incidence of pediatric delirium. Multiinstitutional studies are indicated to further delineate optimal bundles, stratify treatment strategies, and investigate long-term morbidity in pediatric delirium.

A novel workplace-based assessment for competency-based decisions and learner feedback.

BACKGROUND: Increased recognition of the importance of competency-based education and assessment has led to the need for practical and reliable methods to assess relevant skills in the workplace. METHODS: A novel milestone-based workplace assessment system was implemented in 15 pediatrics residency programs. The system provided: (1) web-based multisource feedback (MSF) and structured clinical observation (SCO) instruments that could be completed on any computer or mobile device; and (2) monthly feedback reports that included competency-level scores and recommendations for improvement. RESULTS: For the final instruments, an average of five MSF and 3.7 SCO assessment instruments were completed for each of 292 interns; instruments required an average of 4-8 min to complete. Generalizability coefficients >0.80 were attainable with six MSF observations. Users indicated that the new system added value to their existing assessment program; the need to complete the local assessments in addition to the new assessments was identified as a burden of the overall process. CONCLUSIONS: Outcomes - including high participation rates and high reliability compared to what has traditionally been found with workplace-based assessment - provide evidence for the validity of scores resulting from this novel competency-based assessment system. The development of this assessment model is generalizable to other specialties.

Bacterial diversity differences along an epigenic cave stream reveal evidence of community dynamics, succession, and stability.

Unchanging physicochemical conditions and nutrient sources over long periods of time in cave and karst subsurface habitats, particularly aquifers, can support stable ecosystems, termed autochthonous microbial endokarst communities (AMEC). AMEC existence is unknown for other karst settings, such as epigenic cave streams. Conceptually, AMEC should not form in streams due to faster turnover rates and seasonal disturbances that have the capacity to transport large quantities of water and sediment and to change allochthonous nutrient and organic matter sources. Our goal was to investigate whether AMEC could form and persist in hydrologically active, epigenic cave streams. We analyzed bacterial diversity from cave water, sediments, and artificial substrates (Bio-Traps®) placed in the cave at upstream and downstream locations. Distinct communities existed for the water, sediments, and Bio-Trap® samplers. Throughout the study period, a subset of community members persisted in the water, regardless of hydrological disturbances. Stable habitat conditions based on flow regimes resulted in more than one contemporaneous, stable community throughout the epigenic cave stream. However, evidence for AMEC was insufficient for the cave water or sediments. Community succession, specifically as predictable exogenous heterotrophic microbial community succession, was evident from decreases in community richness from the Bio-Traps®, a peak in Bio-Trap® community biomass, and from changes in the composition of Bio-Trap® communities. The planktonic community was compositionally similar to Bio-Trap® initial colonizers, but the downstream Bio-Trap® community became more similar to the sediment community at the same location. These results can help in understanding the diversity of planktonic and attached microbial communities from karst, as well as microbial community dynamics, stability, and succession during disturbance or contamination responses over time.